A Follow-Up Study of Problem Drinkers Offered a Goal Choice Option PETER G. BOOTH, PH.D., BOB DALE, R.M.N., PETER D. SLADE, PH.D.,* AND MICHAEL E. DEWEY, B.A.* WindsorClinic (ATU), AintreeHospitalsNHS Trust,FazakerleyHospital, LiverpoolL9 7AL, UnitedKingdom
ABSTRACT. Patients (N = 100) who had been admitted to behaviorally orientedresidentialtreatmentfor their drinkingproblemswere followedup for I year. A treatmentgoal option of controlleddrink-
ing was explicitly cateredfor. Overall outcome,in which 27% of thoseavailablefor follow-up were categorizedas "successful,"35% as "equivocal" and 38% as "failure," doesnot appearto be markedly dissimilarto that reportedfrom otheragencies.The distribution of approximatelyequal abstinentand nonabstinentsuccessfulout-
comesis similarto thatfoundfollowingtreatmentprograms thatpromotea singlegoal. Sociodemographic variableswere lessinfluential in predicting outcome thanweretreatment variables--withfrequency of aftercareattendance beingparticularlysignificant.Thosewhohad receivedprevioushospitaltreatmentfor theirproblem,thosewhohabitually drank in companyand thosewho had abnormalblood test resultsprior to enteringtreatmenthad pooreroutcome.(J. Stud. Alcohol 53: 594-600, 1992)
term outcome (Armor et al., 1978; Stinson et al., 1979).
A REVIEW ofprognostic in(Gibbs alcohol treatment outcomepublished priorstudies to 1977 and FlanaPerceptions made by problemdrinkersof importantfacgan, 1977) found no stablecharacteristicsthat were consistently associated with improvement after treatment. However, individual variables, several of which were mea-
suresof socialstabilitysuchas married/cohabiting,higher socialclass, steadywork historyetc., were consideredto be "somewhat more stable predictors."In recent years there has been an increasingtendencyto examinethe contributionsmadeto outcomevarianceby analysisof multiple predictorvariablesand their interactions.The results from suchreportshave generallyshownthat client characteristics,in particularsocialbackground and socialstability indicators,explain the largest proportionof the outcomevariancefollowingtreatmentin a wide variety of settings(Armor et al., 1978; Smart, 1978; Vaillant et al., 1983). Ornsteinand Cherepon(1985), for example,found that older, married and employedclients tended to respond better to treatment but that only aftercare atten-
dance and visits to the' treatmentprogram showed promisingpredictiveability. Whereasinvolvementwith aftercarehas generallybeen foundto be associatedwith positiveoutcome(Vannicelli, 1978; Walker et al., 1983), other treatmentfactors including the length of inpatientstay (Walker et al., 1983) and the setting,contentand styleof the treatmentprovidedare seldomreported to be significantlyinfluential in long-
Received:August15, 1989. Revision:February5, 1991. *Peter D. Sladeis with the Departmentof ClinicalPsychology, New Medical School, Universityof Liverpool, Liverpool, England.Michael E. Deweyis with the UniversityDepartmentof Psychiatry,RoyalLiverpool Hospital,Liverpool. 594
torsin their progresstend to supporta view of treatment's relatively lowly positionin a hierarchyof events(Orford and Edwards,1977). A historyof previoustreatmentad-
missions for alcoholabusehasbeenassociated with poor outcome (Ornstein and Cherepon, 1985; Smart, 1978; Vaillant et al., 1983).
Despitethe methodological variationsand inadequacies of someresearchin the literaturein respectto definitions of patient characteristics,treatmentmethodsand outcome procedures used(Sobellet al., 1987), unqualifiedgeneralizations of saliant prognostic indicators are common within the alcoholabusefield. Psychiatryrevisionnotes, for example,may abbreviateprognosticfactorsto "older; social supportavailable; motivated; first treatment;adequate intelligenceand absenceof anti-socialpersonality traits" (Bird and Harrison, 1982, p. 85). There is some evidencethat patientsare better prognosticators of their own drinking behavior than are staff (Vannicelli and Becker 198l). One comment made by Sobell et al. (1987) was that only a small proportion (2.1%) of the literature under considerationin their (1980-84) review of alcohol treat-
ment outcomeevaluationmethodologywas carried out in the U.K. The majority of the studiesusedoutcomecategoriesthat includednonproblemdrinkingand manywere carried out at agenciesthat had a behavioralorientation. Which of the publisheddata were collectedat treatment settingswhere a nonabstinent drinking goal is explicitly catered for is not clear. Armor et al. (1978) state that, to the bestof their knowledge,noneof the treatmentagencies that provideddata for their study had an explicit controlled-drinking program.
BOOTH
The presentresearchis intendedto (1) describetreatment outcome following admission to behaviorally orientedresidentialtreatmentthat permitsthe adoptionof both abstinentand nonproblemdrinking goals and (2) to investigatethe prognosticinfluence of a variety of variables and their interactions
on outcome in such a treat-
ment setting. Method Patients
ET AL.
595
TABLE1. Descriptionof patientsample(N = 100) usingpredictor variables
Variable
Sampledescription
1. Sex
67 male; 33 female
2. Age
Mean (+ SD): 40.1 + 8.53 years Range: 23-60 51% 42% 38%
3. Married/cohabiting 4. Employed 5. Family historyof heavy drinking 6. Referred by G.P. 7. Previouslyhospitalized 8. Psychotropicmedicationat
39% 52% 61%
intake
One hundredadmissions(nondetoxication)to the Windsor Clinic formed the patient sample.The Alcohol Treat-
9. Maximum abstinenceprior to treatment 10. Abstinencegoal
I week or less:65% (nil: 35%) Range:0 to > 365 days 64%
11. Aftercare
0-4 attendances: 51%
ment Unit (ATU) providesa variety of treatmentoptions in residential,daypatientand outpatientsettings.The inpatientcoursewas progressively shortenedfrom 8 to 6 to 4 weeks during the duration of data collection although the orientationand contentcan be broadly describedas
12. Days as inpatient
behavioral
13. Total aftercare contacts(12
self-control
with
associated
health
education
input.• Clientsareencouraged to formulate explicitplans prior to dischargewhich include proposedstrategiesfor dealing with or avoiding antecedentsto excessivedrinking, limit setting, involvementof significantothers and maintainedcontactwith aftercareand domiciliaryvisiting servicesthat are providedby the ATU for all clientsafter discharge.Feedbackto clients concerningtheir physical examinationand blood test resultsis given routinelyand is usedto assistdecisionmaking in choiceof goal (Booth et al., 1984). The majorityof clientschoosean abstinence goal, and thosethat do not are stronglyadvisedto abstain from alcoholfor 3 monthsor more prior to puttingtheir controlled-drinkingplan into action. Twenty-threevariableswere availablefor all clients and a descriptionof the sampleis presentedin Table 1. Intake variablesare recordedat initial assessment by structured questionnaires.Clients were typically male, aged about forty, married and unemployed.Most drank mainly beer in bars, alone, and consumedmore than 14 pintsdaily--1 pint of beer containsapproximately16 to 20 grams of ethyl alcohol. The pattern of drinking had continuedfor 6 yearson averageand the typicalclient had not managed to abstainfor more than a week prior to assessment.As a consequenceof their alcohol intake, most clients experiencedwithdrawal shakesand somereportedmore severe symptomsof physicaldependency. The majority had biochemicalevidenceof alcohol-relateddamageat initial assessment.
A further requirementfor inclusionin the samplewas that each client, whetherhe/shehad completedthe inpatient courseor had droppedout, providedsufficientquality and quantity of informationthroughoutthe 12 months follow-upperiodto allow categorizationas definedbelow. Followingtheir dischargeall clientswere stronglyencouragedto take up the offer of weekly aftercareappointments
attendance
(none: 19%) 5-21 (n = 16); 22-28 (n = 24); 29-42 (n = 40); 43-62 (n = 20).
months) 14. Abnormal
Range:5-62 Mean: 15.49 + 11.63
Range:2-58 blood results
15. Withdrawalshakesin past 16. DTs in past 17. Palpableliver 18. Daysdrinkingper week
19. Maximumdaily alcoholconsumption 20. Mainly spirit drinkers 21. Mainly home drinkers 22. Mainly solitarydrinkers 23. Durationof drink problem
59%
78% 29% 38% 78% drink daily. Range: 2-7 Mean: 28.8 + 15.5 units Range:8-83 36% 50% 76% Mean:6.30 -+ 5.37 years Range:0.25-20 years
for an indefiniteperiod. In fact, only 81% attendedany aftercare at all and 51% attended on less than five occa-
sionsin the follow-upperiod. The data on theseaftercare dropoutswere gatheredon domiciliaryvisits.Thesewere incorporated into the treatmentpackageat a pre-arranged scheduleof oneeachmonthin the first postdischarge year, althoughthe actual contactrate for individualswas often considerablylessthan this. Explanatorynoteson the predictorvariablesare given in Table 2.
Follow-updata
Clientswere categorizedas "successful,""equivocal" or "failure" in outcomeon the basisof their reportedalcoholconsumption. The treatmentphilosophy of the clinic promotesthe belief that improvementin drinkingstatusis a prerequisiteof changein other potentialproblem areas. A review of literature that reported information about interrelationships betweenoutcomemeasuresfound, with someexceptions,that drinkingbehavioris positivelycorrelated with other outcomeparameters(Maisto and McCollam, 1980). Information that includes reported
596
JOURNAL OF STUDIES ON ALCOHOL / NOVEMBER
TABLE2. Variablesusedin orderedlogisticregressionanalysis
1992
Successful outcomeis definedin the presentstudyas:
Demographic 1. Sex (male vs female).
2. 3. 4. 5.
Age (in years). Marital status(living with a partnervs not). Employmentstatus(employedvs unemployed). Family history(problemdrinkerin immediateblood relativesvs not).
Effectsof previoustreatment 6. Referral(by G.P. vs by other source--mainlypsychiatry). 7. Previoustreatment(previoushospitalization for drink-related problemsvs not). 8. Medication(takingpsychotropic medication--mainlyminor tranquilizersat assessment vs not). 9. Previousattemptsat self-control(maximumperiodof abstinence stated at assessment).
10. Expectationof treatmentgoal (abstinence vs reduced-drinking goal at assessment). Present treatment
11. Aftercare attendance(number of attendancesat clinics during 12-monthfollow-upperiod).
12. Daysas inpatient(generally2, 4, 6, or 8 weekcourses). 13. Total number of aftercare contacts (clinic attendancesand domi-
ciliary visits). Physicaleffects 14. Abnormal blood test results (Gamma GT/MCV above normal at assessment vs not).
15. Withdrawalshakes(ever experiencedby client vs not). 16. DTs (ever experiencedby client vs not). 17. Enlargedliver (palpableliver recordedby M.O. at assessment).
Drinkingvariables 18. Days drinkingin a typicalweek (reportedby client). 19. Maximum amountof alcoholconsumedin any day. 20. Beveragetype (spiritsvs otheralcoholicbeverages). 21. Usual locationof drinking (at home vs not). 22. Usual drinkingcompany(alone vs in company). 23. Durationof problemdrinking(reportedby client).
drinkingintakeis recordedroutinelyat eachaftercarevisit to the ATU. The use and developmentof structured follow-upassessment on domiciliaryvisitshavebeenout-
ß No more than 7 days excessivedrinking reported in the 12 monthsfollowingdischarge(i.e., abstinenceor drinkingwithin the limits advisedby the clinic of no more than eight or six units daily for men and women, respectively).These limits, equivalentto 64 and 48 g ethyl alcohol,were suggested by the Royal Collegeof Psychiatrists (1979). ß A minimum of five face-to-facecontacts(i.e., excludingtelephonecalls) to havebeenmade within the follow-upperiod. ß At least one contactto have been a domiciliary visit. ß No discrepentreports from collateral and/or physical assessment sources.(20 out of 27 in this grouphad supportingconfirmation in this respect).
Twenty-sevenpatientshad successfuloutcome. Equivocaloutcomeis defined as: ß The majority(more than 6 months)of the 12-monthfollow-up periodspentabstinentor drinkingwithin acceptablelevels. ß A minimum
of five face-to-face
contacts to have been made
within the follow-up period. ß No recordof hospitalizationfor alcoholabusethroughoutthe follow-up period.
Thirty-five patientshad equivocaloutcome. Failure is definedas one of the following: ß Hospitalizedfor alcoholabuseproblemsduring the year after discharge(n = 32). ß Deceasedthroughalcohol-relatedcauses(n = 1). ß Evidence, from a minimum of five contactsin the follow-up period,that the majorityof the postdischarge year was spent drinking excessively(n = 5).
Thirty-eight patientswere failuresat outcome.
lined elsewhere (Booth and Dale, 1985).
The validity of self-reportedfollow-up data in a problem-drinking populationcan be questionable.An individual case studythat demonstrates the clinic's sensitivity to this issuehas been publishedelsewhere(Booth, 1990) and there is evidencethat, for clientsnewly referred to this service, generally high levels of agreementare found between spouses'report and clients' self-report (Oxley, 1979). The structureof home-visitingdata collection includesthe provisionfor routinecollateralconfirmation of drinking status.There is, however,wide variation in the quantityof collateralinformationbetweenclients throughoutthe follow-upperiod. Almosthalf the sample, for example,were not married or cohabiting(Table 1). To enhancevalidity of self-report,no prior noticewas given to clientsconcerningthe timing of home visits, and multiple face-to-facecontactswere requiredfor inclusionin the sample.There remains,nevertheless,a proportionof clients who have no collateral
or biochemical
corrobora-
tive data to substantiatetheir self-reporteddrinking status.
Results and Analysis Overall
outcome
The diversityof definitionsadoptedby researchersinvolved in categorizationof alcohol treatment outcome makesdirect comparisonwith the presentresultsdifficult. Within the successful group, however, ß Twelve individualswere totally abstinentfor the year. ß One was totally abstinentexceptfor a bout of drinking in the ninth month which lastedfor 4 days. ß Sevenspentmostof the year totallyabstinentbut had, on several occasions,drunk within recommendeddaily limits. One had exceededher limit--a relapselasting 2 days. ß Four were drinking regularly (usuallyon at least one occasion per week) but within recommended limits. All had abstained for a period of between3 and 10 weeksfollowingdischarge. ß Three were regularcontrolleddrinkerswho had exceededrecommendedlimits on fewer than 7 days in the 12 months.
BOOTH ET AL.
The reported levels of consumptionby the regular drinkersvaried betweenfour and eighteenunitsweekly. All drinkershad at least2 abstinentdaysper week and noneweredrinkingdistilledspirits.The socialsetting,location and beveragetype of regulardrinkerswere often quite differentfrom their typicalpretreatment patternand from that when relapseoccurred.The proportionof totally abstinentclientsin the presentsampleis similarto those reportedby Orford and Edwards(1977) and Smart (1978), 8% and 13%, respectively.In both studiesthere remains an approximatelysimilar proportion of clients who, despiteadvice not to do so, have consumedalcohol without major, if any, problems.A similar balancebetween abstinent and nonabstinent successful outcomes is
found in the presentstudy, althoughtotal abstinenceis the mostpopularinitial goal choice.Goal choiceon leaving hospital--whetherfollowingcompletionof the course or prematurely--was not associatedwith outcomecategory at follow-up, with 59% of the successful,60% of
the equivocaland 58% of the failuregroupsbeingabstinence choosers.
Slightlymore than one-thirdof the sample(38%) were categorizedas failures.In the majorityof thesecases,relapsehad beenassessed as beingof sufficientseverityto warrant admissionfor detoxication(usuallyto either a generalmedicalor a psychiatricward). Owing to the severityof relapseand, in manycases,the confounding of a new agency'srehabilitationefforts with the effectsof our own, failurewas considered the appropriate classification for such readmissions.
The remaining35% of clientsfollowedup, although havingone or more relapseand spendingmore than 7 days(but lessthan 6 months)drinkingheavily,werecategorizedas equivocalin outcome.Nonein this grouphad been hospitalizedfor a drink-relatedproblem in the follow-upperiod. Prediction of treatmentoutcome
An orderedlogisticregressionanalysiswas performed on the data. This techniquewas considered appropriate for relatinga dependentorderedcategoricalvariable(outcome) to both categoricaland continuousindependent variables(predictors).Using all 23 variables(Table 3), chi square for the regressionmodel is 46.99, 23 df,
p = .0022. Significantcontributions of individualpredictor variablesin the equationweremadeby drinkingalone
597
TABLE3. Logisticregression procedure
Variable
[3
SE
X2
p
5.99 3.86 -0.15 -0.01 0.08 -0.30 0.73 -0.39
2.09 2.04 0.75 0.03 0.48 0.50 0.51 0.50
8.24 3.57 0.04 0.13 0.03 0.36 2.05 0.62
.0041 .0589 .8241 .7196 .8665 .5511 .1524 .4315
7. Previous treatment
-1.32
0.61
4.78
.0289*
8. Psychotropics
-0.97
0.52
3.49
.0617
Alpha I Alpha 2 1. Sex 2. Age 3. Cohabiting 4. Employed 5. Family history 6. G.P. referral
9. Max. abstinence
10. Abstinencegoal
0.01
0.02
0.20
.6564
0.27
0.46
0.35
.5544
11. Aftercare
-0.12
0.05
4.98
.0256*
12. Days as inpt.
-0.03
0.02
2.06
.1508
13. Total contacts 14. Blood test fail 15. Shakes 16. D.T.s
0.03 -1.04 -0.44 -0.17
0.05 0.52 0.64 0.57
0.33 4.05 0.47 0.09
.5663 .0442* .4942 .7592
17. Liver enlarged 18. Days drinking 19. Max. total/day 20. Spirit drinker
-0.42 -0.22 0.01 1.26
0.48 0.16 0.02 0.66
0.76 2.95 0.46 3.63
.3823 .0861 .4977 .0567
21. Home drinker 22. Drinks alone 23. Duration
-0.85 1.41 -0.03
0.81 0.61 0.05
1.09 5.41 0.52
.2962 .0201' .4720
*p < .05.
Note: -2 log likelihoodfor modelcontaining intercepts only = 217.73.
ModelX2= 45.42,23 df (scorestat.),p = .0035.Convergence in 5 iterations with 0 step halvings, R = 0.067. Max absolute derivative= 0.7965D - 05. -2 log 1. = 170.74. Model X2 = 46.99 with 23 df. (-2 log 1.r.), p = .0022.
theoretical constructs. The regression analysiswastherefore extendedto considergroupsof variables.All measureswere groupedinto categoriesof "demographic," "previoustreatment,""presenttreatment,""physicaleffects" and "drinking behavior"(seeTable4). Eachcategory of variableswas then deletedas a groupfrom the regression equation,and that group'scontributionto the model was estimatedby comparingit with the results from the analysisusingall 23 predictors.Theseare tabulated in Table 4.
The groupsof demographic, physicaleffectsanddrinking behaviorvariablesdid not significantlyenhancethe accuracyof the regressionanalysiswhereasthose that were categorizedas "presenttreatment"and "previous TABLE4. Logisticregression procedure--groupings of predictor variables
X2 All variables entered
(Z2= 5.41, I df, p = .02)andgreater quantity of aftercare(Z2= 4.98, I df, p = .03)whichwerebothassoci-
Delete demographicvariables
ated with betteroutcome.Havinghad previoustreatment
variables (6, 7, 8, 9, 10) Delete presenttreatment variables (11, 12, 13) Delete physicaleffectsvariables (14, 15, 16, 17) Delete drinkingbehavior variables (18, 19, 20, 21, 22, 23)
(•2 = 4.78, I df, p = .03) andabnormal bloodtestresultsonadmission (•2 = 4.05, 1 df, p = .04)wereboth associated with less successful outcome.
The main interestof predictive studies,however,is not the effect of individualmeasuresbut that of larger
(1, 2, 3, 4, 5)
Diff.
df
p
43.98
3.01
5
NS
35.83
11.16
5
< .05
27.43
19.56
3
< .001
40.72
6.27
4
NS
36.33
10.66
6
NS
46.99
Delete previoustreatment
598
JOURNAL
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ON ALCOHOL
treatment" did. The three variablesrelating to quantityof inpatient and aftercare treatment, in particular, made a highly significant contribution to the overall analysis
(}(2= 19.56,3 df, p < .001).If aftercare attendance is seenas an integral part of the presenttreatmentsystem, rather than as a posttreatmentvariable, the quantity of presenttreatmentis shownto be most importantin esti-
mating eventualoutcomewith this patient group. The contribution
of the five variables
considered
to be associ-
ated with the effectsof pasttreatmentjust achievedstatis-
ticalsignificance (•2 = 11.16,5 df, p • .05). A further analysiswas madeto investigatethe specific contributionof the quantityof inpatienttreatmentto treatment outcome.This issueis of particular importanceas there is presentlya nationwidetendencyto reduce inpatient length of stay while strengtheningoutpatientand daypatientfacilities for problemdrinkers. As mentioned above, the ATU has reducedthe inpatient length of stay. It standsat presentat 3 weeks. Patients in the sample were recodedas belongingto the (approximately)2-week (assessmentonly) course (0 to 21 days), the 4-week closed"block" system(22 to 28 days), the 6-weekcourse (29 to 42 days) and the original 8-week course(43 days and over).
The proportionsof successful,equivocal and failure outcomesin eachlength-of-staygroupingwere not signif-
icantlydifferent(•2= 1.35, 6 df, p = .97). Mean (--- SD) lengthof inpatientstayfor eachoutcomecategory was 33.6 +-13.8 days (successful);34.8 +-13.2 days (equivocal);and 31.4 +- 12.8 days (failure). Thus there seemsto be somesupportfor the progressivereductionin the lengthof inpatientstay for problemdrinkers,particularly when this is accompaniedby a growth of aftercare, outpatientand daypatientfacilities. Discussion
Inferencesthat can be drawnfrom the presentstudyare clearly limited by its descriptivenature. The overall outcome results, however--27% successful,35% equivocal and 38% failure--show proportionsin each outcomecategory similar to thoseelsewherein the literature.Remission rates at 18 months from treatment centers in the Rand
report varied between49% and 81%--although the proportion of noncompletedinterviewswas as high as 64% (Armor et al., 1978). Using different definitions of outcome, Orford and Edwards (1977) had reportedapproxi-
mately equal numbersin the successful,equivocaland failure categories. Within the successful groupspecifically,the proportion of clients who achieve and maintain a nonabstinent out-
comethroughoutthe follow-upyear doesnot appearto be enhanced,despitethe treatmentorientationand the goal choice options, when the presentresultsare compared with others in the literature. A longer term follow-up
/ NOVEMBER
1992
study is in progresswhich should provide information aboutthe stabilityof outcome.The proportionof clients who are successful abstainers at 1 year alsoappearsto be equivalentto resultsreportedelsewhere.Evaluationof a similar treatmentapproachand associatedgoal options with a populationof differentintakecharacteristics, perhapsat an earlier stageof problemdevelopment and level of dependency,would be worthwhile. By excludingclientsfrom the studywho were unableto provide the specified quantity of follow-up data, it is likely that residentiallyunstableclients are underrepresentedin the overall results(Mackenzie et al., 1987). Using similar follow-up proceduresand identical outcome categoriesto the presentresearch,the long-termoutcome report in preparation(referred to above) rejected23% of the total sampleat 1 year postdischarge. The reasonsfor rejectionwere, typically,owing to a move of addressout of the region(9%) and insufficientqualityandquantityof follow-updata (9%). In an earlierstudy,a similarproportion (24%) of a sampleof 49 patientshad been found to be unavailablethroughoutthe 1-yearpostdischarge period (Booth et al., 1984). Were an additional estimated 23%
allocatedentirely to the existingfailure categoryin the present analysis--an extremely conservative strategy, judging from informationactuallyheld on each client up to the point at which data collection was aborted--the proportionsin the successfuland equivocalcategories woulddecreaseto 21% and 28%, respectively.The failure categorywould become51% of the total sample. The intercorrelation betweendifficulty of location,residential instabilityand poor treatmentoutcomemay well give a positive bias to the outcomecategorization,althoughthe inclusionof readmittedrelapsersinto the failure category,whetherthe readmissionoccurredin the first or the twelfth month of follow-up, could counterbalance such bias to some extent.
Comparisonof the findingsfrom the logisticregression analysiswith thosereportedelsewhereis complicatedby differencesbetween or inadequacieswithin methodologies. Several studies(e.g., Armor et al., 1978; Cronkite andMoos, 1978)combinedata collectedfrom a variety of treatmentsettings.A variety of outcomecategoriesare evident also, supportedby varying degreesof collateral confirmation
over different time scales.
The presentstudysuggeststhat problemdrinkerswho have received previous hospital treatment for alcohol abuse--either in other specialistAlcohol TreatmentUnits or, more commonly,for detoxicationin generalmedicalor psychiatricsettings--are less likely to respondto this treatment regimen than are those individuals who have beenhospitalizedfor the first time. An "effectsof previous treatment" groupingof predictorvariablesalso contributes significantly to the regression equation. Newcomersto alcohol inpatienttreatmentprogramsare generallyfound to have a better prognosis(e.g., Smart,
BOOTH
1978;Stinsonet al., 1979). New candidatesmay be more receptiveto any treatmentapproachthan are those who have undergonethe processof hospitalizationon one or more occasionspreviously. Another explanationmight be that hospitalizationis construedby certain candidatesfor treatmentas a sanctuary where the aversiveconsequences of future relapses and alcohol-related behaviors are avoided. There is, in the
presentU.K. socialsecuritysystem,a financialincentive of enhancedbenefit which accompaniessicknesslasting morethan 6 months.Repeatedrelapses,with admissionto hospital,can be seenin someinstancesas part of this process. In addition, when candidates for treatment have subscribed to certain insurance schemes, admission to
hospitalcarries a direct financialbenefit.The majority of repeatadmissionsproveuneventfulin terms of withdrawal symptom severity, even when minimal medication regimens are in use. The phenomenonof hospital admission thus carries
with
it a whole
constellation
of reinforce-
ment-social, financial, psychologicaland physical--and can contributeto the apparentrecidivismof someclients. Patientsusing the serviceare routinelygiven feedback on their biochemical test results. It would appear that those with abnormalitiesresultingfrom excessivealcohol consumptionwere less likely to be successfulfollowing treatment
than were those with normal
blood tests results
at admission.Although the majority of patientsfall into a "severely dependent" category of problem drinking (Booth, 1987), a closer inspectionof the relationshipbetween dependencyand physicaldamagewould be worthwhile. Awareness of physical damage, despite its motivatingpower in a clinical setting,has been found to be unrelated to successful treatment outcome in this treat-
ment setting(Booth et al., 1984). There appearedto be a tendencyfor (the minority of) clients who generallydrank in companyto do worsethan those who were solitary drinkers.The clinic stronglyadvisesthat in no circumstancesshouldany problem drinker attempt to drink alcohol alone after treatment. This is partly the resultof clinical experiencefrom assessment of individualswho have relapsed,but is also supportedby data gatheredin analog drinking experimentswith problem drinkerswhich showspeedof consumptionto be fastest in solitary, as opposedto social, drinking settings (Booth, 1987). It might be the casethat socialreinforcement of excessivedrinkerswho habitually drink in company enhancesthe likelihoodof relapse. Demographicpredictorscontributeproportionatelyless to the regressionanalysisthan is found in other research reports.Marital statusand employmentstatuscan be construednot only as indicesof social stability but also as potential posttreatmentvariables. It might be expected that a client who returnsafter treatmentto a partner and employmentwould havea considerableadvantageover his peer returningto an empty houseand unemployment.One
ET AL.
599
couldhypothesize, however,that the aftercaresupportsystem is more easily taken up by and more attractiveto (in respectto free meals,socialactivitiesandcompanionship) thoseof low socialstabilityand that the prognosticvariablesof high social stabilityand aftercareattendanceinteract in this respect. Aftercare attendancehas generally been found to be prognostic of good treatment outcome (Ornstein and Cherepon,1983;Walkeret al., 1983). RegularAlcoholics Anonymousattendancefollowingtreatmenthas beenassociated with good outcome in several studies(Pettinati et al., 1982;Vaillantet al., 1983). When frequencyof aftercare attendanceis includedin a pregenttreatmentgrouping of variables,a significantproportionof the variability in outcomeis predictedin the presentresearch.This proportion would appearto be considerablyhigherthan that attributableto sociodemographic factors. With such a high degreeof attrition in alcohol abuse treatment,it would be a sensibleprincipleto encourage clientsto stay in treatmenteither by direct adviceto those who had droppedout (Booth and Dale, 1985) or by more subtlemethodsassociatedwith the makingof aftercarefacilities attractive and appealing. The cost of intensive follow-up methods,which enhancethe likelihoodof treatment completion,is likely to limit their generalapplication (Gilbert, 1988). The resultsof the presentstudy suggestthat, for a 12 monthspostdischargeperiod at least, the outcome after treatmentwhere alternativegoal optionsare availableis similarto that followingsomeprogramswith a singleabstinencegoal. The similarity is evidentboth in the overall outcomeclassificationand in the proportionsof abstinent and nonabstinentoutcomesin the successfulcategory.
Consistentwith other reportsconductedat a variety of agenciesand healthcare settings,lengthof inpatientstay doesnot appearto influencetreatmentoutcome;a history of previoushospitaladmissionsfor alcoholabuseis associated with poor outcome;and maintainedcontactwith aftercare, following dischargefrom hospital, enhancesthe likelihood
of success.
Unlike otherprognosticstudies,the presentdata do not support the importanceof sociodemographic factors in predicting outcome. A treatment category of variables was found to contributesignificantlyto the regression analysisapplied to the data. Acknowledgment The authorswish to expresstheir gratitudeto Dr. J.M.A. Ansari and the staffsof the Windsorand Lakesideclinicsfor their supportand encouragement in the presentstudy. Note
1. Furtherdetailsof the treatmentprogramsusedat the WindsorClinic are available from the first author.
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/ NOVEMBER
1992
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GIBBS,L. ANDFLANAGAN, J. Prognosticindicatorsof alcoholismtreatment outcome. Int. J. Addict. 12: 1097-1141, 1977.
GILBERT,F.S. The effect of type of aftercare follow-up on treatment
outcomeamongalcoholics. J. Stud.Alcohol49: 149-159,1988. MACKENZIE,A., FUNDERBURK, F.R., ALLEN, R.P. AND STEFAN,R.L. The characteristics of alcoholics frequentlylostto follow-up.J. Stud. Alcohol 48: 119-123, 1987.
MAISTO,S.A. AND MCCOLLAM,J.B. The use of multiple measuresof life health to assess alcohol treatment outcome: A review and cri-
tique. In: SOBELL, L.C., SOBELL, M.B. ANDWARD,E. (Eds.)Evaluating Alcohol and Drug Abuse TreatmentEffectiveness:Recent Advances,Elmsford,N.Y.: PergamonPress,Inc., 1980, pp. 15-76. ORFORD,J. ANDEDWARDS, G. Alcoholism:A Comparisonof Treatment
ORNSTEIN,P. AND CHEREPON, J.A. Demographicvariablesas predictors of alcoholism treatment outcome. J. Stud. Alcohol 46: 425-432, 1985.
OXLEY,E. The Reliabilityand Validity of Alcoholics'Self-Report,M. Psychol.Dissertation,Universityof Liverpool, 1979. PETTINATI, H.M.,
SUGERMAN, A.A.,
DIDONATO, N. AND MAURER,
H.S. The natural history of alcoholismover four years after treatment. J. Stud. Alcohol 43: 201-215, 1982. ROYAL COLLEGEOF PSYCHIATRISTS. Alcohol and Alcoholism, London: Tavistock, 1979.
SMART,R.G. Do some alcoholicsdo better in some types of treatment than others?Drug Alcohol Depend. 3: 65-75, 1978. SOBELL,M.B., BROCHU,S., SOBELL,L.C., ROY, J. AND STEVENS,J.A. Alcohol treatmentoutcomeevaluationmethodology:Stateof the art 1980-1984. Addict. Behav. 12: 113-128, 1987. STINSON, D.J., SMITH, W.G., AMIDJAYA, I. AND KAPLAN, J.M.
Systemsof care andtreatmentoutcomesfor alcoholicpatients.Arch. gen. Psychiat.36: 535-539, 1979. VAILLANT, G.E., CLARK, W., CYRUS, C., MILOFSKY,E.S., KOPP, J.,
WULSIN,V.W. ANDMOGIELNICKI, N.P. Prospectivestudyof alcoholismtreatment:Eight-yearfollow-up.Amen J. Med. 75: 455-463, 1983.
VANNICELLI,m. Impact of aftercarein the treatmentof alcoholics:A cross-lagged panelanalysis.J. Stud. Alcohol39: 1875-1886,1978. VANNICELLI,m. AND BECKER,B. Predictionof outcomein treatmentof
alcoholism:A studyof staff and patients.J. Stud. Alcohol42: 938950, 1981. WALKER, R.D.,
DONOVAN, D.M.,
KIVLAHAN, D.R. AND O'LEARY,
M.R. Length of stay, neuropsychological performance,and aftercare:Influenceson alcoholtreatmentoutcome.J. cons.clin. Psychol. 51: 900-911, 1983.
ABSTRACT. Patients (N = 100) who had been admitted to behaviorally orientedresidentialtreatmentfor their drinkingproblemswere followedup for I year. A treatmentgoal option of controlleddrink-
ing was explicitly cateredfor. Overall outcome,in which 27% of thoseavailablefor follow-up were categorizedas "successful,"35% as "equivocal" and 38% as "failure," doesnot appearto be markedly dissimilarto that reportedfrom otheragencies.The distribution of approximatelyequal abstinentand nonabstinentsuccessfulout-
comesis similarto thatfoundfollowingtreatmentprograms thatpromotea singlegoal. Sociodemographic variableswere lessinfluential in predicting outcome thanweretreatment variables--withfrequency of aftercareattendance beingparticularlysignificant.Thosewhohad receivedprevioushospitaltreatmentfor theirproblem,thosewhohabitually drank in companyand thosewho had abnormalblood test resultsprior to enteringtreatmenthad pooreroutcome.(J. Stud. Alcohol 53: 594-600, 1992)
term outcome (Armor et al., 1978; Stinson et al., 1979).
A REVIEW ofprognostic in(Gibbs alcohol treatment outcomepublished priorstudies to 1977 and FlanaPerceptions made by problemdrinkersof importantfacgan, 1977) found no stablecharacteristicsthat were consistently associated with improvement after treatment. However, individual variables, several of which were mea-
suresof socialstabilitysuchas married/cohabiting,higher socialclass, steadywork historyetc., were consideredto be "somewhat more stable predictors."In recent years there has been an increasingtendencyto examinethe contributionsmadeto outcomevarianceby analysisof multiple predictorvariablesand their interactions.The results from suchreportshave generallyshownthat client characteristics,in particularsocialbackground and socialstability indicators,explain the largest proportionof the outcomevariancefollowingtreatmentin a wide variety of settings(Armor et al., 1978; Smart, 1978; Vaillant et al., 1983). Ornsteinand Cherepon(1985), for example,found that older, married and employedclients tended to respond better to treatment but that only aftercare atten-
dance and visits to the' treatmentprogram showed promisingpredictiveability. Whereasinvolvementwith aftercarehas generallybeen foundto be associatedwith positiveoutcome(Vannicelli, 1978; Walker et al., 1983), other treatmentfactors including the length of inpatientstay (Walker et al., 1983) and the setting,contentand styleof the treatmentprovidedare seldomreported to be significantlyinfluential in long-
Received:August15, 1989. Revision:February5, 1991. *Peter D. Sladeis with the Departmentof ClinicalPsychology, New Medical School, Universityof Liverpool, Liverpool, England.Michael E. Deweyis with the UniversityDepartmentof Psychiatry,RoyalLiverpool Hospital,Liverpool. 594
torsin their progresstend to supporta view of treatment's relatively lowly positionin a hierarchyof events(Orford and Edwards,1977). A historyof previoustreatmentad-
missions for alcoholabusehasbeenassociated with poor outcome (Ornstein and Cherepon, 1985; Smart, 1978; Vaillant et al., 1983).
Despitethe methodological variationsand inadequacies of someresearchin the literaturein respectto definitions of patient characteristics,treatmentmethodsand outcome procedures used(Sobellet al., 1987), unqualifiedgeneralizations of saliant prognostic indicators are common within the alcoholabusefield. Psychiatryrevisionnotes, for example,may abbreviateprognosticfactorsto "older; social supportavailable; motivated; first treatment;adequate intelligenceand absenceof anti-socialpersonality traits" (Bird and Harrison, 1982, p. 85). There is some evidencethat patientsare better prognosticators of their own drinking behavior than are staff (Vannicelli and Becker 198l). One comment made by Sobell et al. (1987) was that only a small proportion (2.1%) of the literature under considerationin their (1980-84) review of alcohol treat-
ment outcomeevaluationmethodologywas carried out in the U.K. The majority of the studiesusedoutcomecategoriesthat includednonproblemdrinkingand manywere carried out at agenciesthat had a behavioralorientation. Which of the publisheddata were collectedat treatment settingswhere a nonabstinent drinking goal is explicitly catered for is not clear. Armor et al. (1978) state that, to the bestof their knowledge,noneof the treatmentagencies that provideddata for their study had an explicit controlled-drinking program.
BOOTH
The presentresearchis intendedto (1) describetreatment outcome following admission to behaviorally orientedresidentialtreatmentthat permitsthe adoptionof both abstinentand nonproblemdrinking goals and (2) to investigatethe prognosticinfluence of a variety of variables and their interactions
on outcome in such a treat-
ment setting. Method Patients
ET AL.
595
TABLE1. Descriptionof patientsample(N = 100) usingpredictor variables
Variable
Sampledescription
1. Sex
67 male; 33 female
2. Age
Mean (+ SD): 40.1 + 8.53 years Range: 23-60 51% 42% 38%
3. Married/cohabiting 4. Employed 5. Family historyof heavy drinking 6. Referred by G.P. 7. Previouslyhospitalized 8. Psychotropicmedicationat
39% 52% 61%
intake
One hundredadmissions(nondetoxication)to the Windsor Clinic formed the patient sample.The Alcohol Treat-
9. Maximum abstinenceprior to treatment 10. Abstinencegoal
I week or less:65% (nil: 35%) Range:0 to > 365 days 64%
11. Aftercare
0-4 attendances: 51%
ment Unit (ATU) providesa variety of treatmentoptions in residential,daypatientand outpatientsettings.The inpatientcoursewas progressively shortenedfrom 8 to 6 to 4 weeks during the duration of data collection although the orientationand contentcan be broadly describedas
12. Days as inpatient
behavioral
13. Total aftercare contacts(12
self-control
with
associated
health
education
input.• Clientsareencouraged to formulate explicitplans prior to dischargewhich include proposedstrategiesfor dealing with or avoiding antecedentsto excessivedrinking, limit setting, involvementof significantothers and maintainedcontactwith aftercareand domiciliaryvisiting servicesthat are providedby the ATU for all clientsafter discharge.Feedbackto clients concerningtheir physical examinationand blood test resultsis given routinelyand is usedto assistdecisionmaking in choiceof goal (Booth et al., 1984). The majorityof clientschoosean abstinence goal, and thosethat do not are stronglyadvisedto abstain from alcoholfor 3 monthsor more prior to puttingtheir controlled-drinkingplan into action. Twenty-threevariableswere availablefor all clients and a descriptionof the sampleis presentedin Table 1. Intake variablesare recordedat initial assessment by structured questionnaires.Clients were typically male, aged about forty, married and unemployed.Most drank mainly beer in bars, alone, and consumedmore than 14 pintsdaily--1 pint of beer containsapproximately16 to 20 grams of ethyl alcohol. The pattern of drinking had continuedfor 6 yearson averageand the typicalclient had not managed to abstainfor more than a week prior to assessment.As a consequenceof their alcohol intake, most clients experiencedwithdrawal shakesand somereportedmore severe symptomsof physicaldependency. The majority had biochemicalevidenceof alcohol-relateddamageat initial assessment.
A further requirementfor inclusionin the samplewas that each client, whetherhe/shehad completedthe inpatient courseor had droppedout, providedsufficientquality and quantity of informationthroughoutthe 12 months follow-upperiodto allow categorizationas definedbelow. Followingtheir dischargeall clientswere stronglyencouragedto take up the offer of weekly aftercareappointments
attendance
(none: 19%) 5-21 (n = 16); 22-28 (n = 24); 29-42 (n = 40); 43-62 (n = 20).
months) 14. Abnormal
Range:5-62 Mean: 15.49 + 11.63
Range:2-58 blood results
15. Withdrawalshakesin past 16. DTs in past 17. Palpableliver 18. Daysdrinkingper week
19. Maximumdaily alcoholconsumption 20. Mainly spirit drinkers 21. Mainly home drinkers 22. Mainly solitarydrinkers 23. Durationof drink problem
59%
78% 29% 38% 78% drink daily. Range: 2-7 Mean: 28.8 + 15.5 units Range:8-83 36% 50% 76% Mean:6.30 -+ 5.37 years Range:0.25-20 years
for an indefiniteperiod. In fact, only 81% attendedany aftercare at all and 51% attended on less than five occa-
sionsin the follow-upperiod. The data on theseaftercare dropoutswere gatheredon domiciliaryvisits.Thesewere incorporated into the treatmentpackageat a pre-arranged scheduleof oneeachmonthin the first postdischarge year, althoughthe actual contactrate for individualswas often considerablylessthan this. Explanatorynoteson the predictorvariablesare given in Table 2.
Follow-updata
Clientswere categorizedas "successful,""equivocal" or "failure" in outcomeon the basisof their reportedalcoholconsumption. The treatmentphilosophy of the clinic promotesthe belief that improvementin drinkingstatusis a prerequisiteof changein other potentialproblem areas. A review of literature that reported information about interrelationships betweenoutcomemeasuresfound, with someexceptions,that drinkingbehavioris positivelycorrelated with other outcomeparameters(Maisto and McCollam, 1980). Information that includes reported
596
JOURNAL OF STUDIES ON ALCOHOL / NOVEMBER
TABLE2. Variablesusedin orderedlogisticregressionanalysis
1992
Successful outcomeis definedin the presentstudyas:
Demographic 1. Sex (male vs female).
2. 3. 4. 5.
Age (in years). Marital status(living with a partnervs not). Employmentstatus(employedvs unemployed). Family history(problemdrinkerin immediateblood relativesvs not).
Effectsof previoustreatment 6. Referral(by G.P. vs by other source--mainlypsychiatry). 7. Previoustreatment(previoushospitalization for drink-related problemsvs not). 8. Medication(takingpsychotropic medication--mainlyminor tranquilizersat assessment vs not). 9. Previousattemptsat self-control(maximumperiodof abstinence stated at assessment).
10. Expectationof treatmentgoal (abstinence vs reduced-drinking goal at assessment). Present treatment
11. Aftercare attendance(number of attendancesat clinics during 12-monthfollow-upperiod).
12. Daysas inpatient(generally2, 4, 6, or 8 weekcourses). 13. Total number of aftercare contacts (clinic attendancesand domi-
ciliary visits). Physicaleffects 14. Abnormal blood test results (Gamma GT/MCV above normal at assessment vs not).
15. Withdrawalshakes(ever experiencedby client vs not). 16. DTs (ever experiencedby client vs not). 17. Enlargedliver (palpableliver recordedby M.O. at assessment).
Drinkingvariables 18. Days drinkingin a typicalweek (reportedby client). 19. Maximum amountof alcoholconsumedin any day. 20. Beveragetype (spiritsvs otheralcoholicbeverages). 21. Usual locationof drinking (at home vs not). 22. Usual drinkingcompany(alone vs in company). 23. Durationof problemdrinking(reportedby client).
drinkingintakeis recordedroutinelyat eachaftercarevisit to the ATU. The use and developmentof structured follow-upassessment on domiciliaryvisitshavebeenout-
ß No more than 7 days excessivedrinking reported in the 12 monthsfollowingdischarge(i.e., abstinenceor drinkingwithin the limits advisedby the clinic of no more than eight or six units daily for men and women, respectively).These limits, equivalentto 64 and 48 g ethyl alcohol,were suggested by the Royal Collegeof Psychiatrists (1979). ß A minimum of five face-to-facecontacts(i.e., excludingtelephonecalls) to havebeenmade within the follow-upperiod. ß At least one contactto have been a domiciliary visit. ß No discrepentreports from collateral and/or physical assessment sources.(20 out of 27 in this grouphad supportingconfirmation in this respect).
Twenty-sevenpatientshad successfuloutcome. Equivocaloutcomeis defined as: ß The majority(more than 6 months)of the 12-monthfollow-up periodspentabstinentor drinkingwithin acceptablelevels. ß A minimum
of five face-to-face
contacts to have been made
within the follow-up period. ß No recordof hospitalizationfor alcoholabusethroughoutthe follow-up period.
Thirty-five patientshad equivocaloutcome. Failure is definedas one of the following: ß Hospitalizedfor alcoholabuseproblemsduring the year after discharge(n = 32). ß Deceasedthroughalcohol-relatedcauses(n = 1). ß Evidence, from a minimum of five contactsin the follow-up period,that the majorityof the postdischarge year was spent drinking excessively(n = 5).
Thirty-eight patientswere failuresat outcome.
lined elsewhere (Booth and Dale, 1985).
The validity of self-reportedfollow-up data in a problem-drinking populationcan be questionable.An individual case studythat demonstrates the clinic's sensitivity to this issuehas been publishedelsewhere(Booth, 1990) and there is evidencethat, for clientsnewly referred to this service, generally high levels of agreementare found between spouses'report and clients' self-report (Oxley, 1979). The structureof home-visitingdata collection includesthe provisionfor routinecollateralconfirmation of drinking status.There is, however,wide variation in the quantityof collateralinformationbetweenclients throughoutthe follow-upperiod. Almosthalf the sample, for example,were not married or cohabiting(Table 1). To enhancevalidity of self-report,no prior noticewas given to clientsconcerningthe timing of home visits, and multiple face-to-facecontactswere requiredfor inclusionin the sample.There remains,nevertheless,a proportionof clients who have no collateral
or biochemical
corrobora-
tive data to substantiatetheir self-reporteddrinking status.
Results and Analysis Overall
outcome
The diversityof definitionsadoptedby researchersinvolved in categorizationof alcohol treatment outcome makesdirect comparisonwith the presentresultsdifficult. Within the successful group, however, ß Twelve individualswere totally abstinentfor the year. ß One was totally abstinentexceptfor a bout of drinking in the ninth month which lastedfor 4 days. ß Sevenspentmostof the year totallyabstinentbut had, on several occasions,drunk within recommendeddaily limits. One had exceededher limit--a relapselasting 2 days. ß Four were drinking regularly (usuallyon at least one occasion per week) but within recommended limits. All had abstained for a period of between3 and 10 weeksfollowingdischarge. ß Three were regularcontrolleddrinkerswho had exceededrecommendedlimits on fewer than 7 days in the 12 months.
BOOTH ET AL.
The reported levels of consumptionby the regular drinkersvaried betweenfour and eighteenunitsweekly. All drinkershad at least2 abstinentdaysper week and noneweredrinkingdistilledspirits.The socialsetting,location and beveragetype of regulardrinkerswere often quite differentfrom their typicalpretreatment patternand from that when relapseoccurred.The proportionof totally abstinentclientsin the presentsampleis similarto those reportedby Orford and Edwards(1977) and Smart (1978), 8% and 13%, respectively.In both studiesthere remains an approximatelysimilar proportion of clients who, despiteadvice not to do so, have consumedalcohol without major, if any, problems.A similar balancebetween abstinent and nonabstinent successful outcomes is
found in the presentstudy, althoughtotal abstinenceis the mostpopularinitial goal choice.Goal choiceon leaving hospital--whetherfollowingcompletionof the course or prematurely--was not associatedwith outcomecategory at follow-up, with 59% of the successful,60% of
the equivocaland 58% of the failuregroupsbeingabstinence choosers.
Slightlymore than one-thirdof the sample(38%) were categorizedas failures.In the majorityof thesecases,relapsehad beenassessed as beingof sufficientseverityto warrant admissionfor detoxication(usuallyto either a generalmedicalor a psychiatricward). Owing to the severityof relapseand, in manycases,the confounding of a new agency'srehabilitationefforts with the effectsof our own, failurewas considered the appropriate classification for such readmissions.
The remaining35% of clientsfollowedup, although havingone or more relapseand spendingmore than 7 days(but lessthan 6 months)drinkingheavily,werecategorizedas equivocalin outcome.Nonein this grouphad been hospitalizedfor a drink-relatedproblem in the follow-upperiod. Prediction of treatmentoutcome
An orderedlogisticregressionanalysiswas performed on the data. This techniquewas considered appropriate for relatinga dependentorderedcategoricalvariable(outcome) to both categoricaland continuousindependent variables(predictors).Using all 23 variables(Table 3), chi square for the regressionmodel is 46.99, 23 df,
p = .0022. Significantcontributions of individualpredictor variablesin the equationweremadeby drinkingalone
597
TABLE3. Logisticregression procedure
Variable
[3
SE
X2
p
5.99 3.86 -0.15 -0.01 0.08 -0.30 0.73 -0.39
2.09 2.04 0.75 0.03 0.48 0.50 0.51 0.50
8.24 3.57 0.04 0.13 0.03 0.36 2.05 0.62
.0041 .0589 .8241 .7196 .8665 .5511 .1524 .4315
7. Previous treatment
-1.32
0.61
4.78
.0289*
8. Psychotropics
-0.97
0.52
3.49
.0617
Alpha I Alpha 2 1. Sex 2. Age 3. Cohabiting 4. Employed 5. Family history 6. G.P. referral
9. Max. abstinence
10. Abstinencegoal
0.01
0.02
0.20
.6564
0.27
0.46
0.35
.5544
11. Aftercare
-0.12
0.05
4.98
.0256*
12. Days as inpt.
-0.03
0.02
2.06
.1508
13. Total contacts 14. Blood test fail 15. Shakes 16. D.T.s
0.03 -1.04 -0.44 -0.17
0.05 0.52 0.64 0.57
0.33 4.05 0.47 0.09
.5663 .0442* .4942 .7592
17. Liver enlarged 18. Days drinking 19. Max. total/day 20. Spirit drinker
-0.42 -0.22 0.01 1.26
0.48 0.16 0.02 0.66
0.76 2.95 0.46 3.63
.3823 .0861 .4977 .0567
21. Home drinker 22. Drinks alone 23. Duration
-0.85 1.41 -0.03
0.81 0.61 0.05
1.09 5.41 0.52
.2962 .0201' .4720
*p < .05.
Note: -2 log likelihoodfor modelcontaining intercepts only = 217.73.
ModelX2= 45.42,23 df (scorestat.),p = .0035.Convergence in 5 iterations with 0 step halvings, R = 0.067. Max absolute derivative= 0.7965D - 05. -2 log 1. = 170.74. Model X2 = 46.99 with 23 df. (-2 log 1.r.), p = .0022.
theoretical constructs. The regression analysiswastherefore extendedto considergroupsof variables.All measureswere groupedinto categoriesof "demographic," "previoustreatment,""presenttreatment,""physicaleffects" and "drinking behavior"(seeTable4). Eachcategory of variableswas then deletedas a groupfrom the regression equation,and that group'scontributionto the model was estimatedby comparingit with the results from the analysisusingall 23 predictors.Theseare tabulated in Table 4.
The groupsof demographic, physicaleffectsanddrinking behaviorvariablesdid not significantlyenhancethe accuracyof the regressionanalysiswhereasthose that were categorizedas "presenttreatment"and "previous TABLE4. Logisticregression procedure--groupings of predictor variables
X2 All variables entered
(Z2= 5.41, I df, p = .02)andgreater quantity of aftercare(Z2= 4.98, I df, p = .03)whichwerebothassoci-
Delete demographicvariables
ated with betteroutcome.Havinghad previoustreatment
variables (6, 7, 8, 9, 10) Delete presenttreatment variables (11, 12, 13) Delete physicaleffectsvariables (14, 15, 16, 17) Delete drinkingbehavior variables (18, 19, 20, 21, 22, 23)
(•2 = 4.78, I df, p = .03) andabnormal bloodtestresultsonadmission (•2 = 4.05, 1 df, p = .04)wereboth associated with less successful outcome.
The main interestof predictive studies,however,is not the effect of individualmeasuresbut that of larger
(1, 2, 3, 4, 5)
Diff.
df
p
43.98
3.01
5
NS
35.83
11.16
5
< .05
27.43
19.56
3
< .001
40.72
6.27
4
NS
36.33
10.66
6
NS
46.99
Delete previoustreatment
598
JOURNAL
OF STUDIES
ON ALCOHOL
treatment" did. The three variablesrelating to quantityof inpatient and aftercare treatment, in particular, made a highly significant contribution to the overall analysis
(}(2= 19.56,3 df, p < .001).If aftercare attendance is seenas an integral part of the presenttreatmentsystem, rather than as a posttreatmentvariable, the quantity of presenttreatmentis shownto be most importantin esti-
mating eventualoutcomewith this patient group. The contribution
of the five variables
considered
to be associ-
ated with the effectsof pasttreatmentjust achievedstatis-
ticalsignificance (•2 = 11.16,5 df, p • .05). A further analysiswas madeto investigatethe specific contributionof the quantityof inpatienttreatmentto treatment outcome.This issueis of particular importanceas there is presentlya nationwidetendencyto reduce inpatient length of stay while strengtheningoutpatientand daypatientfacilities for problemdrinkers. As mentioned above, the ATU has reducedthe inpatient length of stay. It standsat presentat 3 weeks. Patients in the sample were recodedas belongingto the (approximately)2-week (assessmentonly) course (0 to 21 days), the 4-week closed"block" system(22 to 28 days), the 6-weekcourse (29 to 42 days) and the original 8-week course(43 days and over).
The proportionsof successful,equivocal and failure outcomesin eachlength-of-staygroupingwere not signif-
icantlydifferent(•2= 1.35, 6 df, p = .97). Mean (--- SD) lengthof inpatientstayfor eachoutcomecategory was 33.6 +-13.8 days (successful);34.8 +-13.2 days (equivocal);and 31.4 +- 12.8 days (failure). Thus there seemsto be somesupportfor the progressivereductionin the lengthof inpatientstay for problemdrinkers,particularly when this is accompaniedby a growth of aftercare, outpatientand daypatientfacilities. Discussion
Inferencesthat can be drawnfrom the presentstudyare clearly limited by its descriptivenature. The overall outcome results, however--27% successful,35% equivocal and 38% failure--show proportionsin each outcomecategory similar to thoseelsewherein the literature.Remission rates at 18 months from treatment centers in the Rand
report varied between49% and 81%--although the proportion of noncompletedinterviewswas as high as 64% (Armor et al., 1978). Using different definitions of outcome, Orford and Edwards (1977) had reportedapproxi-
mately equal numbersin the successful,equivocaland failure categories. Within the successful groupspecifically,the proportion of clients who achieve and maintain a nonabstinent out-
comethroughoutthe follow-upyear doesnot appearto be enhanced,despitethe treatmentorientationand the goal choice options, when the presentresultsare compared with others in the literature. A longer term follow-up
/ NOVEMBER
1992
study is in progresswhich should provide information aboutthe stabilityof outcome.The proportionof clients who are successful abstainers at 1 year alsoappearsto be equivalentto resultsreportedelsewhere.Evaluationof a similar treatmentapproachand associatedgoal options with a populationof differentintakecharacteristics, perhapsat an earlier stageof problemdevelopment and level of dependency,would be worthwhile. By excludingclientsfrom the studywho were unableto provide the specified quantity of follow-up data, it is likely that residentiallyunstableclients are underrepresentedin the overall results(Mackenzie et al., 1987). Using similar follow-up proceduresand identical outcome categoriesto the presentresearch,the long-termoutcome report in preparation(referred to above) rejected23% of the total sampleat 1 year postdischarge. The reasonsfor rejectionwere, typically,owing to a move of addressout of the region(9%) and insufficientqualityandquantityof follow-updata (9%). In an earlierstudy,a similarproportion (24%) of a sampleof 49 patientshad been found to be unavailablethroughoutthe 1-yearpostdischarge period (Booth et al., 1984). Were an additional estimated 23%
allocatedentirely to the existingfailure categoryin the present analysis--an extremely conservative strategy, judging from informationactuallyheld on each client up to the point at which data collection was aborted--the proportionsin the successfuland equivocalcategories woulddecreaseto 21% and 28%, respectively.The failure categorywould become51% of the total sample. The intercorrelation betweendifficulty of location,residential instabilityand poor treatmentoutcomemay well give a positive bias to the outcomecategorization,althoughthe inclusionof readmittedrelapsersinto the failure category,whetherthe readmissionoccurredin the first or the twelfth month of follow-up, could counterbalance such bias to some extent.
Comparisonof the findingsfrom the logisticregression analysiswith thosereportedelsewhereis complicatedby differencesbetween or inadequacieswithin methodologies. Several studies(e.g., Armor et al., 1978; Cronkite andMoos, 1978)combinedata collectedfrom a variety of treatmentsettings.A variety of outcomecategoriesare evident also, supportedby varying degreesof collateral confirmation
over different time scales.
The presentstudysuggeststhat problemdrinkerswho have received previous hospital treatment for alcohol abuse--either in other specialistAlcohol TreatmentUnits or, more commonly,for detoxicationin generalmedicalor psychiatricsettings--are less likely to respondto this treatment regimen than are those individuals who have beenhospitalizedfor the first time. An "effectsof previous treatment" groupingof predictorvariablesalso contributes significantly to the regression equation. Newcomersto alcohol inpatienttreatmentprogramsare generallyfound to have a better prognosis(e.g., Smart,
BOOTH
1978;Stinsonet al., 1979). New candidatesmay be more receptiveto any treatmentapproachthan are those who have undergonethe processof hospitalizationon one or more occasionspreviously. Another explanationmight be that hospitalizationis construedby certain candidatesfor treatmentas a sanctuary where the aversiveconsequences of future relapses and alcohol-related behaviors are avoided. There is, in the
presentU.K. socialsecuritysystem,a financialincentive of enhancedbenefit which accompaniessicknesslasting morethan 6 months.Repeatedrelapses,with admissionto hospital,can be seenin someinstancesas part of this process. In addition, when candidates for treatment have subscribed to certain insurance schemes, admission to
hospitalcarries a direct financialbenefit.The majority of repeatadmissionsproveuneventfulin terms of withdrawal symptom severity, even when minimal medication regimens are in use. The phenomenonof hospital admission thus carries
with
it a whole
constellation
of reinforce-
ment-social, financial, psychologicaland physical--and can contributeto the apparentrecidivismof someclients. Patientsusing the serviceare routinelygiven feedback on their biochemical test results. It would appear that those with abnormalitiesresultingfrom excessivealcohol consumptionwere less likely to be successfulfollowing treatment
than were those with normal
blood tests results
at admission.Although the majority of patientsfall into a "severely dependent" category of problem drinking (Booth, 1987), a closer inspectionof the relationshipbetween dependencyand physicaldamagewould be worthwhile. Awareness of physical damage, despite its motivatingpower in a clinical setting,has been found to be unrelated to successful treatment outcome in this treat-
ment setting(Booth et al., 1984). There appearedto be a tendencyfor (the minority of) clients who generallydrank in companyto do worsethan those who were solitary drinkers.The clinic stronglyadvisesthat in no circumstancesshouldany problem drinker attempt to drink alcohol alone after treatment. This is partly the resultof clinical experiencefrom assessment of individualswho have relapsed,but is also supportedby data gatheredin analog drinking experimentswith problem drinkerswhich showspeedof consumptionto be fastest in solitary, as opposedto social, drinking settings (Booth, 1987). It might be the casethat socialreinforcement of excessivedrinkerswho habitually drink in company enhancesthe likelihoodof relapse. Demographicpredictorscontributeproportionatelyless to the regressionanalysisthan is found in other research reports.Marital statusand employmentstatuscan be construednot only as indicesof social stability but also as potential posttreatmentvariables. It might be expected that a client who returnsafter treatmentto a partner and employmentwould havea considerableadvantageover his peer returningto an empty houseand unemployment.One
ET AL.
599
couldhypothesize, however,that the aftercaresupportsystem is more easily taken up by and more attractiveto (in respectto free meals,socialactivitiesandcompanionship) thoseof low socialstabilityand that the prognosticvariablesof high social stabilityand aftercareattendanceinteract in this respect. Aftercare attendancehas generally been found to be prognostic of good treatment outcome (Ornstein and Cherepon,1983;Walkeret al., 1983). RegularAlcoholics Anonymousattendancefollowingtreatmenthas beenassociated with good outcome in several studies(Pettinati et al., 1982;Vaillantet al., 1983). When frequencyof aftercare attendanceis includedin a pregenttreatmentgrouping of variables,a significantproportionof the variability in outcomeis predictedin the presentresearch.This proportion would appearto be considerablyhigherthan that attributableto sociodemographic factors. With such a high degreeof attrition in alcohol abuse treatment,it would be a sensibleprincipleto encourage clientsto stay in treatmenteither by direct adviceto those who had droppedout (Booth and Dale, 1985) or by more subtlemethodsassociatedwith the makingof aftercarefacilities attractive and appealing. The cost of intensive follow-up methods,which enhancethe likelihoodof treatment completion,is likely to limit their generalapplication (Gilbert, 1988). The resultsof the presentstudy suggestthat, for a 12 monthspostdischargeperiod at least, the outcome after treatmentwhere alternativegoal optionsare availableis similarto that followingsomeprogramswith a singleabstinencegoal. The similarity is evidentboth in the overall outcomeclassificationand in the proportionsof abstinent and nonabstinentoutcomesin the successfulcategory.
Consistentwith other reportsconductedat a variety of agenciesand healthcare settings,lengthof inpatientstay doesnot appearto influencetreatmentoutcome;a history of previoushospitaladmissionsfor alcoholabuseis associated with poor outcome;and maintainedcontactwith aftercare, following dischargefrom hospital, enhancesthe likelihood
of success.
Unlike otherprognosticstudies,the presentdata do not support the importanceof sociodemographic factors in predicting outcome. A treatment category of variables was found to contributesignificantlyto the regression analysisapplied to the data. Acknowledgment The authorswish to expresstheir gratitudeto Dr. J.M.A. Ansari and the staffsof the Windsorand Lakesideclinicsfor their supportand encouragement in the presentstudy. Note
1. Furtherdetailsof the treatmentprogramsusedat the WindsorClinic are available from the first author.
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