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The use of a videotape pretherapy training program to encourage treatment-seeking among alcohol detoxification patients
BEHAVIOR THERAPY 11, 141--147 (1980)
The Use of a Videotape Pretherapy Training Program to Encourage Treatment-Seeking Among Alcohol Detoxification Patients FREDERIC C. CRAIGIE, JR.
Central Maine Family Practice Residency
S'rEVEN M. Ross Salt Lake City Veterans Administration Hospital and University of Utah Two alternative programs were utilized to encourage 31 male alcohol detoxification patients to become involved with treatment for alcoholism. The experimental (pretherapy training) procedure used videotaped modeling with subsequent discussion in an effort to encourage problem disclosure, to counteract denial, and to communicate information about treatment and the benefits that might be expected. A comparison procedure consisted of commercially available films and discussion which were considered to provide very general exhortations to viewers to remain abstinent from alcohol. Results indicated greater treatmentseeking on the part of experimental subjects. Experimental subjects left detoxification with a treatment referral and made initial treatment contacts significantly more than comparison subjects. Follow-up data suggested that experimental subjects who entered treatment programs may have been more successful in treatment than comparison subjects who entered programs.
Alcoholism in the United States has had enormous personal and financial costs. Part of the problem is that alcoholics have tended not to become involved and follow through with rehabilitative treatment. Of the estimated 10 million alcoholics in America, only about 1.2 million have This study is based on a dissertation submitted by the first author to the Department of Psychology at the University of Utah in partial fulfillment of the requirements for the Ph.D. degree. The study was begun while the first author was a psychology trainee at the Salt Lake City Veterans Administration Hospital. Support was provided the first author daring the latter stages of the project by the University of Utah Department of Psychology and the Copper Mountain Mental Health Center Adolescent Day Treatment Program in Murray, UT. The authors wish to thank Jim Alexander, Dale Cannon, Tom Malloy, Stu Proctor, and Dave Shaw for their contributions to the dissertation. Address inquiries for reprints to Frederic C. Craigie, Jr., Central Maine Family Practice Residency, 12 East Chestnut Street, Augusta, ME 04330.
14 1 0005-7894/80/0141-014751.00/0 Copyright 1980by Associationfor Advancementof BehaviorTherapy All rightsof reproductionin any formreserved.
142
C R A I G I E A N D ROSS
become involved with treatment, half of them in Alcoholics Anonymous (National Clearinghouse on Alcohol Information, Note 1). Even among people surfacing in health care systems with identified alcohol problems, the rate at which follow-up treatment contact is made has been estimated not to exceed 20% (Homer, Note 2). Direct contingencies may be effective in encouraging alcoholic treatment-seeking. Rosenberg and Liftik (1976) reported that contact and attendance rates of coerced patients (e.g., for whom treatment was a condition of probation) were superior to those of voluntary patients. Miller (1975) utilized a system of positive incentives (housing, employment, meals, clothing, etc.) to foster treatment contact and sobriety among skid row alcoholics. In the absence of such contingencies, treatment involvement rates have been particularly low (Mayer, 1972; Wanberg & Jones, 1973). The present study utilized videotaped modeling with subsequent discussion in an effort to encourage male veterans with identified alcohol problems to seek treatment. This approach is based on social-learning literature (Bandura, 1969) that demonstrates that vicarious experiences can significantly affect observers' performances. It is also based on the pretherapy training literature (e.g., Goldstein, Heller, & Sechrest, 1966; Heitler, 1973; Sauber, 1974; Strupp & Bloxom, 1973), which suggests that informing clients of the nature, requirements, and likely benefits of treatment can facilitate therapeutic success. It was predicted that subjects exposed to the pretherapy training procedure would follow through with treatment to a greater extent than comparison subjects.
METHOD Participants and Setting Subjects were 31 male alcohol detoxification patients at a western Veterans Administration Hospital. Subjects' mean age was 48.0 years. Of the subjects, 58% had had previous hospital detoxification episodes; the same proportion had documented and/or reported prior alcohol treatment experiences. There were no significant differences between experimental and comparison-group subjects with regard to these variables or with regard to length of education, marital status, employment status, involvement in alcohol-related legal problems, or residential distance from the hospital. All patients who presented with primary or secondary diagnoses of alcohol withdrawal during the period of the study were considered for participation. Detoxification patients who were judged by ward staff to show evidence of chronic organic brain syndrome or thought disorder, who were currently involved with any alcohol treatment program, whose projected or actual detoxification stays were not long enough to complete treatment procedures, or who chose not to participate were excluded from participation.
PRETHERAPY TRAINING
143
Design of the Study The experimenter met with each qualified patient as soon as medically feasible to introduce and describe the project and explain confidentiality precautions. Patients who agreed to participate were then asked to read and sign consent forms. Intervention. Subjects were randomly assigned to either of two pretraining conditions? Both conditions involved three sessions in which the experimenter met individually with the subject. Each session in both conditions included a videotape and discussion. Sessions lasted an average of 35-40 minutes. The experimental (pretherapy training) procedure consisted of videotapes which modeled specific target behaviors in short vignettes. Actors who modeled appropriate target behaviors (problem disclosure and willingness to "try treatment") were said to have favorably resolved their alcohol problems. Actors who modeled inappropriate target behaviors (denial of problems and of the need to "try treatment") were said to have been "headed for trouble." (The most frequent forms of problem denial, for modeling purposes, were ascertained by administering a questionnaire to detoxification and treatment staff.) The experimental videotapes also included vignettes which illustrated and described several aspects of what treatment was like, such as identifying specific antecedents of alcohol use and dealing with them with particular coping skills. The latter procedure was intended to dispel myths about treatment and communicate specific positive expectations about "trying treatment." Discussion in the experimental condition consisted of additional efforts to encourage problem disclosure and counteract denial and to communicate additional information about treatment and the benefits that might be expected. The comparison procedure was intended to be comparable to the experimental procedure in terms of amount and modalities of treatment contact. The comparison procedure consisted of videotapes of the films Chalk Talk (Martin, 1972) and Medical Aspects of Alcohol (Schneider, 1975), which were considered to provide very general exhortations to viewers to remain abstinent from alcohol. Discussion in the comparison condition emphasized the need to stop drinking, encouraged subjects to get into treatment, and informed them how they could arrange to get into treatment (e.g., by indicating their interest in treatment to appropriate ward staff). The experimenter did not refer subjects for treatment. Experimental Prior and subsequent to intervention in both groups, subjects met with an undergraduate research assistant. These sessions consisted of tape-recorded, semistructured interviews, followed by the administration of three questionnaires. Questions were designed to elicit subjects' perceptions of their drinking and other problems, Data from these sessions were only marginally valid and did not substantially contribute to interpreting results. Further information may be obtained from the authors.
144
CRAIGIE AND ROSS TABLE 1 PROPORTION OF SUBJECTS IN EXPERIMENTAL AND COMPARISON GROUPS ACHIEVING TREATMENT-SEEKING CRITERION MEASURES Group
Criterion Leaves detoxification with other than an irregular discharge Leaves detoxification with a treatment referral Makes an initial treatment contact
Experimental ( N = 14)
Cornparison ( N = 17)
Z
.86
.76
.72
.64 .50
.18 .18
2.90** 1.99"
* p < .05. ** p < .01.
procedures encouraged subjects to initiate and follow through with the referral process. The actual referral process, however, was handled by ward staff who were not aware of the nature of experimental conditions or of the condition assignment of particular subjects.
Dependent Measures The main dependent measure of the study was the extent to which subjects followed through with postdetoxification alcoholic rehabilitation. A three-step hierarchical scale was used to measure this. The first step was "leaves detoxification with other than a regular discharge"; the second, "leaves with a treatment follow-up referral"; the third (and most important), "makes an initial treatment contact." For purposes of the latter measure, it was decided prior to data collection that subjects would be allowed a maximum of 2 weeks following the completion of detoxification to make an initial treatment contact. For each of the three steps, differences between experimental and comparison subjects were evaluated with a test for significance of difference between two proportions (Bruning & Kintz, 1968). In addition, the length of stay and discharge condition of subjects who began postdetoxification treatment were determined.
RESULTS
Treatment-Seeking Subjects exposed to the experimental (pretherapy training) procedure made initial treatment contacts significantly more than subjects exposed to the comparison procedure (Z = 1.99, p < .05). Experimental subjects also left detoxification with a follow-up referral significantly more than comparison subjects (Z = 2.90, p < .01). There was no significant difference in the proportions of the experimental and comparison subjects
PRETHERAPY TRAINING
145
leaving detoxification with other than an irregular discharge. These data are presented in Table 1.
Postdetoxification Follow-up Subjects were followed to the extent possible after their completion of detoxification. All of the six experimental subjects who entered inpatient treatment programs remained over 50 days. Four of the six successfully completed programs. All experimental subjects who became involved with outpatient treatment (one direct from detox., three as a continuation of inpatient treatment) remained in treatment at the time of follow-up, a minimum of 51 days since initial outpatient contact. One of the three comparison subjects who made an initial treatment contact successfully completed an inpatient program but did not return for outpatient followup and was dropped. The other two comparison subjects who made initial treatment contacts left "irregular" after 68 days of outpatient treatment and 7 days of inpatient treatment, respectively.
DISCUSSION The experimental (pretherapy training) procedure was found to be effective in increasing treatment-seeking among detoxification patients. Experimental group subjects received treatment referrals and made initial treatment contacts significantly more than comparison group subjects. In addition, experimental subjects who made treatment contact tended to remain longer and complete treatment to a greater extent than comparison subjects who made treatment contact. The latter findings, of course, are only suggestive because of the small number of subjects involved. These results are consistent with the prediction that therapeutic involvement may be facilitated by modeling relevant behaviors and by describing the nature and expected benefits of treatment. The pretherapy training procedure emphasized the point that drinking problems are typically interrelated with a number of other problems (interpersonal, cognitive, affective, etc.). In both films and discussion, experimental subjects were cautioned that it would be difficult to remain sober unless they identified and worked out other problems that frequently are antecedents of alcohol use. The comparison procedure was much more directly geared toward alcohol abuse and drinking problems per se. Part of the effectiveness of the experimental procedure, therefore, may have been due to convincing subjects of the multifaceted nature of their problems and pointing out the specific ways in which multimodal treatment could help work them out. In contrast, subjects' reported recognition of alcohol problems per se may have been high enough initially that the comparison procedure's focus on alcohol abuse and drinking problems did not substantially alter comparison subjects' pictures of their predicaments. The suggestive follow-up data on enhanced treatment success of experimental subjects are also consistent with literature on pretherapy training. Numerous investigators (e.g., Baekeland & Lundwall, 1975; Gold-
146
CRAIGIE AND ROSS
stein et al., 1966; Yalom, 1970) have observed that inadequate preparation of clients for psychotherapy is associated with high attrition and poor measures of therapy process and outcome among clients who remain in treatment. Adequate preparation regarding the nature, requirements, and likely benefits of treatment have been associated with the opposite results. Of course, the present procedures cannot clearly identify mechanisms of effectiveness of the experimental intervention. Subsequent research on this topic might begin to isolate the relative contributions of videotaped modeling, discussion, encouraging problem disclosure, counteracting denial, describing the nature and benefits of treatment, and so forth. A potential confound is that of experimenter bias. The experimenter conducted the intervention for both subject groups. Although he spent a slightly higher average amount of time with comparison subjects (116 minutes) than with experimental subjects (103 minutes), he may still have subtly exerted different amounts of effort with the two groups. Future replications should change this design feature.
REFERENCE NOTES 1. National Clearinghouse on Alcohol Information (U.S. Department of Health, Education and Welfare, Public Health Service). Personal Communication, April I l, 1979. 2. Homer, A. Unpublished data, 1977. (Available from Pilot Alcohol and Drug Abuse Treatment Unit (116A9), Veterans Administration Hospital, Salt Lake City, UT 84148.)
REFERENCES Bandura, A. Principles of behavior modification. New York: Holt, Rinehart & Winston, 1969. Baekeland, F., & Lundwall, L. Dropping out of treatment: A critical review. Psychological Bulletin, 1975, 82, 738-783. Bruning, J. L., & Kintz, B . L . Computational handbook of statistics. Glenview, IL: Scott, Foresman & Company, 1968. Goldstein, A. P., Heller, K., & Sechrest, L. B. Psychotherapy and the psychology of behavior change. New York: Wiley, 1966. Heitler, J. B. Preparation of lower-class patients for expressive group psychotherapy. Journal of Consulting and Clinical Psychology, 1973, 41,251-260. Martin, J. (Producer). Chalk talk. Havre de Grace, MD: Father Martin Associates, 1972. (Film) Mayer, J. Initial alcoholism clinic attendance of patients with legal referrals. Quarterly Journal of Studies on Alcohol, 1972, 33, 814-816. Miller, P.M. A behavioral intervention program for chronic public drunkenness offenders. Archives of General Psychiatry, 1975, 32, 915-918. Rosenberg, C. M., & Liftik, J. Use of coercion in the outpatient treatment of alcoholism. Journal of Studies on Alcohol, 1976, 37, 58-63. Sauber, S . R . Approaches to pretherapy training. Journal of Contemporary Psychotherapy, 1974, 6, 190-197. Schneider, M. A. (Producer). Medical aspects of alcohol. Hollywood, CA: Visual Exchange, 1975. (Film)
PRETHERAPY TRAINING
147
Strupp, H. H., & Bloxom, A . L . Preparing lower-class patients for group psychotherapy: Development and evaluation of a role-induction film. Journal of Consulting and Clinical Psychology, 1973, 41, 373-384. Wanberg, K. W., & Jones, E. Initial contact and admission of persons requesting treatment for alcohol problems. British Journal of the Addictions, 1973, 68, 281-285. Yalom, I . D . The theory and practice of group psychotherapy. New York: Basic Books, 1970. RECEIVED: July 2, 1979; REVISED: September 13, 1979 FINAL ACCEPTANCE: September 18, 1979
The Use of a Videotape Pretherapy Training Program to Encourage Treatment-Seeking Among Alcohol Detoxification Patients FREDERIC C. CRAIGIE, JR.
Central Maine Family Practice Residency
S'rEVEN M. Ross Salt Lake City Veterans Administration Hospital and University of Utah Two alternative programs were utilized to encourage 31 male alcohol detoxification patients to become involved with treatment for alcoholism. The experimental (pretherapy training) procedure used videotaped modeling with subsequent discussion in an effort to encourage problem disclosure, to counteract denial, and to communicate information about treatment and the benefits that might be expected. A comparison procedure consisted of commercially available films and discussion which were considered to provide very general exhortations to viewers to remain abstinent from alcohol. Results indicated greater treatmentseeking on the part of experimental subjects. Experimental subjects left detoxification with a treatment referral and made initial treatment contacts significantly more than comparison subjects. Follow-up data suggested that experimental subjects who entered treatment programs may have been more successful in treatment than comparison subjects who entered programs.
Alcoholism in the United States has had enormous personal and financial costs. Part of the problem is that alcoholics have tended not to become involved and follow through with rehabilitative treatment. Of the estimated 10 million alcoholics in America, only about 1.2 million have This study is based on a dissertation submitted by the first author to the Department of Psychology at the University of Utah in partial fulfillment of the requirements for the Ph.D. degree. The study was begun while the first author was a psychology trainee at the Salt Lake City Veterans Administration Hospital. Support was provided the first author daring the latter stages of the project by the University of Utah Department of Psychology and the Copper Mountain Mental Health Center Adolescent Day Treatment Program in Murray, UT. The authors wish to thank Jim Alexander, Dale Cannon, Tom Malloy, Stu Proctor, and Dave Shaw for their contributions to the dissertation. Address inquiries for reprints to Frederic C. Craigie, Jr., Central Maine Family Practice Residency, 12 East Chestnut Street, Augusta, ME 04330.
14 1 0005-7894/80/0141-014751.00/0 Copyright 1980by Associationfor Advancementof BehaviorTherapy All rightsof reproductionin any formreserved.
142
C R A I G I E A N D ROSS
become involved with treatment, half of them in Alcoholics Anonymous (National Clearinghouse on Alcohol Information, Note 1). Even among people surfacing in health care systems with identified alcohol problems, the rate at which follow-up treatment contact is made has been estimated not to exceed 20% (Homer, Note 2). Direct contingencies may be effective in encouraging alcoholic treatment-seeking. Rosenberg and Liftik (1976) reported that contact and attendance rates of coerced patients (e.g., for whom treatment was a condition of probation) were superior to those of voluntary patients. Miller (1975) utilized a system of positive incentives (housing, employment, meals, clothing, etc.) to foster treatment contact and sobriety among skid row alcoholics. In the absence of such contingencies, treatment involvement rates have been particularly low (Mayer, 1972; Wanberg & Jones, 1973). The present study utilized videotaped modeling with subsequent discussion in an effort to encourage male veterans with identified alcohol problems to seek treatment. This approach is based on social-learning literature (Bandura, 1969) that demonstrates that vicarious experiences can significantly affect observers' performances. It is also based on the pretherapy training literature (e.g., Goldstein, Heller, & Sechrest, 1966; Heitler, 1973; Sauber, 1974; Strupp & Bloxom, 1973), which suggests that informing clients of the nature, requirements, and likely benefits of treatment can facilitate therapeutic success. It was predicted that subjects exposed to the pretherapy training procedure would follow through with treatment to a greater extent than comparison subjects.
METHOD Participants and Setting Subjects were 31 male alcohol detoxification patients at a western Veterans Administration Hospital. Subjects' mean age was 48.0 years. Of the subjects, 58% had had previous hospital detoxification episodes; the same proportion had documented and/or reported prior alcohol treatment experiences. There were no significant differences between experimental and comparison-group subjects with regard to these variables or with regard to length of education, marital status, employment status, involvement in alcohol-related legal problems, or residential distance from the hospital. All patients who presented with primary or secondary diagnoses of alcohol withdrawal during the period of the study were considered for participation. Detoxification patients who were judged by ward staff to show evidence of chronic organic brain syndrome or thought disorder, who were currently involved with any alcohol treatment program, whose projected or actual detoxification stays were not long enough to complete treatment procedures, or who chose not to participate were excluded from participation.
PRETHERAPY TRAINING
143
Design of the Study The experimenter met with each qualified patient as soon as medically feasible to introduce and describe the project and explain confidentiality precautions. Patients who agreed to participate were then asked to read and sign consent forms. Intervention. Subjects were randomly assigned to either of two pretraining conditions? Both conditions involved three sessions in which the experimenter met individually with the subject. Each session in both conditions included a videotape and discussion. Sessions lasted an average of 35-40 minutes. The experimental (pretherapy training) procedure consisted of videotapes which modeled specific target behaviors in short vignettes. Actors who modeled appropriate target behaviors (problem disclosure and willingness to "try treatment") were said to have favorably resolved their alcohol problems. Actors who modeled inappropriate target behaviors (denial of problems and of the need to "try treatment") were said to have been "headed for trouble." (The most frequent forms of problem denial, for modeling purposes, were ascertained by administering a questionnaire to detoxification and treatment staff.) The experimental videotapes also included vignettes which illustrated and described several aspects of what treatment was like, such as identifying specific antecedents of alcohol use and dealing with them with particular coping skills. The latter procedure was intended to dispel myths about treatment and communicate specific positive expectations about "trying treatment." Discussion in the experimental condition consisted of additional efforts to encourage problem disclosure and counteract denial and to communicate additional information about treatment and the benefits that might be expected. The comparison procedure was intended to be comparable to the experimental procedure in terms of amount and modalities of treatment contact. The comparison procedure consisted of videotapes of the films Chalk Talk (Martin, 1972) and Medical Aspects of Alcohol (Schneider, 1975), which were considered to provide very general exhortations to viewers to remain abstinent from alcohol. Discussion in the comparison condition emphasized the need to stop drinking, encouraged subjects to get into treatment, and informed them how they could arrange to get into treatment (e.g., by indicating their interest in treatment to appropriate ward staff). The experimenter did not refer subjects for treatment. Experimental Prior and subsequent to intervention in both groups, subjects met with an undergraduate research assistant. These sessions consisted of tape-recorded, semistructured interviews, followed by the administration of three questionnaires. Questions were designed to elicit subjects' perceptions of their drinking and other problems, Data from these sessions were only marginally valid and did not substantially contribute to interpreting results. Further information may be obtained from the authors.
144
CRAIGIE AND ROSS TABLE 1 PROPORTION OF SUBJECTS IN EXPERIMENTAL AND COMPARISON GROUPS ACHIEVING TREATMENT-SEEKING CRITERION MEASURES Group
Criterion Leaves detoxification with other than an irregular discharge Leaves detoxification with a treatment referral Makes an initial treatment contact
Experimental ( N = 14)
Cornparison ( N = 17)
Z
.86
.76
.72
.64 .50
.18 .18
2.90** 1.99"
* p < .05. ** p < .01.
procedures encouraged subjects to initiate and follow through with the referral process. The actual referral process, however, was handled by ward staff who were not aware of the nature of experimental conditions or of the condition assignment of particular subjects.
Dependent Measures The main dependent measure of the study was the extent to which subjects followed through with postdetoxification alcoholic rehabilitation. A three-step hierarchical scale was used to measure this. The first step was "leaves detoxification with other than a regular discharge"; the second, "leaves with a treatment follow-up referral"; the third (and most important), "makes an initial treatment contact." For purposes of the latter measure, it was decided prior to data collection that subjects would be allowed a maximum of 2 weeks following the completion of detoxification to make an initial treatment contact. For each of the three steps, differences between experimental and comparison subjects were evaluated with a test for significance of difference between two proportions (Bruning & Kintz, 1968). In addition, the length of stay and discharge condition of subjects who began postdetoxification treatment were determined.
RESULTS
Treatment-Seeking Subjects exposed to the experimental (pretherapy training) procedure made initial treatment contacts significantly more than subjects exposed to the comparison procedure (Z = 1.99, p < .05). Experimental subjects also left detoxification with a follow-up referral significantly more than comparison subjects (Z = 2.90, p < .01). There was no significant difference in the proportions of the experimental and comparison subjects
PRETHERAPY TRAINING
145
leaving detoxification with other than an irregular discharge. These data are presented in Table 1.
Postdetoxification Follow-up Subjects were followed to the extent possible after their completion of detoxification. All of the six experimental subjects who entered inpatient treatment programs remained over 50 days. Four of the six successfully completed programs. All experimental subjects who became involved with outpatient treatment (one direct from detox., three as a continuation of inpatient treatment) remained in treatment at the time of follow-up, a minimum of 51 days since initial outpatient contact. One of the three comparison subjects who made an initial treatment contact successfully completed an inpatient program but did not return for outpatient followup and was dropped. The other two comparison subjects who made initial treatment contacts left "irregular" after 68 days of outpatient treatment and 7 days of inpatient treatment, respectively.
DISCUSSION The experimental (pretherapy training) procedure was found to be effective in increasing treatment-seeking among detoxification patients. Experimental group subjects received treatment referrals and made initial treatment contacts significantly more than comparison group subjects. In addition, experimental subjects who made treatment contact tended to remain longer and complete treatment to a greater extent than comparison subjects who made treatment contact. The latter findings, of course, are only suggestive because of the small number of subjects involved. These results are consistent with the prediction that therapeutic involvement may be facilitated by modeling relevant behaviors and by describing the nature and expected benefits of treatment. The pretherapy training procedure emphasized the point that drinking problems are typically interrelated with a number of other problems (interpersonal, cognitive, affective, etc.). In both films and discussion, experimental subjects were cautioned that it would be difficult to remain sober unless they identified and worked out other problems that frequently are antecedents of alcohol use. The comparison procedure was much more directly geared toward alcohol abuse and drinking problems per se. Part of the effectiveness of the experimental procedure, therefore, may have been due to convincing subjects of the multifaceted nature of their problems and pointing out the specific ways in which multimodal treatment could help work them out. In contrast, subjects' reported recognition of alcohol problems per se may have been high enough initially that the comparison procedure's focus on alcohol abuse and drinking problems did not substantially alter comparison subjects' pictures of their predicaments. The suggestive follow-up data on enhanced treatment success of experimental subjects are also consistent with literature on pretherapy training. Numerous investigators (e.g., Baekeland & Lundwall, 1975; Gold-
146
CRAIGIE AND ROSS
stein et al., 1966; Yalom, 1970) have observed that inadequate preparation of clients for psychotherapy is associated with high attrition and poor measures of therapy process and outcome among clients who remain in treatment. Adequate preparation regarding the nature, requirements, and likely benefits of treatment have been associated with the opposite results. Of course, the present procedures cannot clearly identify mechanisms of effectiveness of the experimental intervention. Subsequent research on this topic might begin to isolate the relative contributions of videotaped modeling, discussion, encouraging problem disclosure, counteracting denial, describing the nature and benefits of treatment, and so forth. A potential confound is that of experimenter bias. The experimenter conducted the intervention for both subject groups. Although he spent a slightly higher average amount of time with comparison subjects (116 minutes) than with experimental subjects (103 minutes), he may still have subtly exerted different amounts of effort with the two groups. Future replications should change this design feature.
REFERENCE NOTES 1. National Clearinghouse on Alcohol Information (U.S. Department of Health, Education and Welfare, Public Health Service). Personal Communication, April I l, 1979. 2. Homer, A. Unpublished data, 1977. (Available from Pilot Alcohol and Drug Abuse Treatment Unit (116A9), Veterans Administration Hospital, Salt Lake City, UT 84148.)
REFERENCES Bandura, A. Principles of behavior modification. New York: Holt, Rinehart & Winston, 1969. Baekeland, F., & Lundwall, L. Dropping out of treatment: A critical review. Psychological Bulletin, 1975, 82, 738-783. Bruning, J. L., & Kintz, B . L . Computational handbook of statistics. Glenview, IL: Scott, Foresman & Company, 1968. Goldstein, A. P., Heller, K., & Sechrest, L. B. Psychotherapy and the psychology of behavior change. New York: Wiley, 1966. Heitler, J. B. Preparation of lower-class patients for expressive group psychotherapy. Journal of Consulting and Clinical Psychology, 1973, 41,251-260. Martin, J. (Producer). Chalk talk. Havre de Grace, MD: Father Martin Associates, 1972. (Film) Mayer, J. Initial alcoholism clinic attendance of patients with legal referrals. Quarterly Journal of Studies on Alcohol, 1972, 33, 814-816. Miller, P.M. A behavioral intervention program for chronic public drunkenness offenders. Archives of General Psychiatry, 1975, 32, 915-918. Rosenberg, C. M., & Liftik, J. Use of coercion in the outpatient treatment of alcoholism. Journal of Studies on Alcohol, 1976, 37, 58-63. Sauber, S . R . Approaches to pretherapy training. Journal of Contemporary Psychotherapy, 1974, 6, 190-197. Schneider, M. A. (Producer). Medical aspects of alcohol. Hollywood, CA: Visual Exchange, 1975. (Film)
PRETHERAPY TRAINING
147
Strupp, H. H., & Bloxom, A . L . Preparing lower-class patients for group psychotherapy: Development and evaluation of a role-induction film. Journal of Consulting and Clinical Psychology, 1973, 41, 373-384. Wanberg, K. W., & Jones, E. Initial contact and admission of persons requesting treatment for alcohol problems. British Journal of the Addictions, 1973, 68, 281-285. Yalom, I . D . The theory and practice of group psychotherapy. New York: Basic Books, 1970. RECEIVED: July 2, 1979; REVISED: September 13, 1979 FINAL ACCEPTANCE: September 18, 1979