Vol. 14. No. 4 July/August 1990
0145-6008/90/ I404-0584$2.00/0 Al.COllOl ISM: CI I h K ’ A I . A N I > E V P l K l h l t Y T A l RI.SI.AHCII
Inpatient Treatment of Employed Alcoholics: A Randomized Clinical Trial on Hazelden-Type and Traditional Treatment Lauri Keso and Mikko Salaspuro
The first randomized clinical trial on the Hazelden-type of treatment showed that this AA-oriented treatment for alcoholism can result in significant improvement in drinking behavior as compared to a more traditional form of treatment. One hundred forty-one employed alcoholics were randomized to either Hazelden-type treatment (N = 74) or to traditional-type treatment (N = 67). The treatment groups were highly comparable. The bimonthly follow-up lasted one year. According to the COPES-questionnaire(short form), the treatment at the Hazelden-type institute was significantly more involving, supportive, encouraging to spontaneity and oriented to personal problems than at the traditional-type institute. In accordance the treatment drop-out rate was 7.9% at Hazelden-type institute and 25.9% at traditional-type institute (p < 0.02). The participation in outpatient treatment was significantly better after the Hazelden-type treatment. The proportion of those abstinent (admitted ethanol consumption, 0 g/day; gammaglutamyl transferase, and mean cell volume were normal) was higher at Hazelden-type institute during the last (8-12 months) follow-up period (26.3% vs. 9.8%, p = 0.05). Fourteen percent of the Hazeldon-type institute patients and 1.9% of the traditional-type institute patients stayed abstinent during the whole 1-year follow-up period (p < 0.05). The differences for the corresponding rates for controlled drinking (admitted ethanol consumption less than 40 g/day, GGT, and MCV normal) were in the same direction but did not reach statistical significance. Thus the Hazelden-type treatment obtained better results in 1-year abstinence rate than a more traditional-type treatment. Key Words: Alcohol Dependency, Treatment, Clinical Trial
LCOHOLlSM IS THE major health problem among A employed population.’-4At present there are numerous different types of treatment available for alcoholics.’ Nevertheless convincing demonstration of their general efficiency is still lacking.’ On the contrary there is, for example, a major study showing no difference between treatment and “advice” (the “advice” consisted of one counseling session).‘ A new form of inpatient treatment, with strong ties to the AA-movement, has been developed in the Hazeldenclinic in Minnesota with claims for high recovery percentage among the patients.’-’ This Hazelden-type treatment has during the past spread throughout North America and
Scandinavia. Nevertheless controlled evaluations of its treatment results are lacking. The aim of our study was to compare the treatment results obtained by a Hazeldon-type treatment institute and the leading traditional-type treatment institute in Finland among employed alcoholics. PATIENTS AND METHODS The Puiicnrs Two hundred thirty-five employed alcoholics were sent to our outpatient clinic by their occupational health agency for the evaluation and direction to inpatient treatment. Ninety-one (38.7%)of them were not eligible for the study and thus were not randomized. The eligibility of the patients for the study was established in a I-hr long semistructured interview with a physician (who was one of the authors. LK). During the interview the patients’ social and medical history were covered as well as alcohol and drug use history. After the interview a detailed medical check-up was done. The exclusion criteria were the patients who ( I ) didn’t have serious problems with alcohol (didn’t meet the DSM-3 criteria for alcohol dependency), ( 2 ) refused either inpatient treatment or follow-up. (3) wanted to attend treatment in a specific institution, (4) were unable to fill the study questionnaires, (5) were a drug addict (i.e.. used or had used any illicit drugs ever), ( 6 ) were expected to be imprisoned during the follow-up period, (7) and whose state of health precluded normal life (long treatment period in a hospital was needed or patient suffered from serious brain damage or severe psychiatric illness). Almost all the exclusions were due to criteria 2 and 3 (58 and 32 patients. respectively). Fifty patients refused inpatient treatment but agreed to outpatient treatment in alcohol clinics. and eight patients refused all treatment. Altogether. 176 patients attended inpatient treatment and 8 I .8% (144) of these were randomized. Three patients were excluded from the analysis after the randomization. We were unable to include them to either treatment group since they did not attend the treatment they were randomized to but instead attended the other institute. Thus, the study group consisted of 141 patients. They were randomized (closed envelope method) to either Kalliola ( N= 74. Hazelden-type treatment) or Jarvenpaa ( N= 67. traditional-type treatment). The treatment groups were highly comparable with each other (Table I ) .
Thc Trwl men[ Ins1 it 111 P.S The treatment in Kalliola is based on the Minnesota (Hazelden)model. It treats only employed alcoholics. The center has 28 beds and a staff of 12 persons. The staff consists of a manager. a physician. a social therapist. a nurse, two therapists, four nonprofessional workers. a secretary. and a research worker. Eleven of the 12 staff members are active in AA. In accordance with the AA-principles. the basic aim of the treatment is to achieve enduring abstinence. To achieve this the rehabilitation . 4 h f i o / U r n E . Y Rns. ~ Vol 14. No 4. 1990: pp 584-589
585
INPATIENT TREATMENT OF EMPLOYED ALCOHOLICS center uses a highly structured treatment scheme which includes ( I ) lectures about alcohol physiology, (2) lectures with discussion about the mental structure of alcoholics and the alcoholic way of thinking, ( 3 ) the AA-program. (4) personal therapy, and (5) once a week group therapy sessions. The treatment period is 28 days. Each patient is introduced to an AA-member who helps the patient after the treatment period is over. With the help of this person, the patient is expected to start participating in the local AA-meetings. The treatment in Jarvenpaa has its foundations in the traditions of social work and psychiatric treatment. It gives treatment to all alcoholics (not only employed) and also to their families when necessary. Drug addicts are also treated. It has 168 beds and a staff of about 90 persons. Among them are three physicians (one of them. a specialist in psychiatry, is the manager of the institute), social therapists, psychiatric nurses, foremen, psychologists, a chaplain, a sports instructor, and offce workers, etc.. Members of AA are rare among the staff. The Institute consists of five wards (one of them for family treatment: however, none of the study patients were assigned to family treatment) in the main building, a smaller building for kindergarten, glass houses, cultivated grounds, work shops, sporting grounds, and room for various recreational activities. The aim of the treatment is the psychic, physical, and social rehabilitation of the addicts. Abstinence is recommended, but the specific treatment aims are worked out in co-operation with the patient. The main treatments used are ( I ) personal therapy, (2) various group therapy methods, (3) family therapy, and (4) work therapy. The patient receives at the most 8 hours of psychotherapy each week if work therapy is not included; in most instances less than that. During the working hours the patients are usually ( I ) working at work shops, cultivated grounds etc., (2) taking part in various sports, or ( 3 )thinking or reading in their rooms. One or two therapy sessions are included in daily activities. During the evenings and weekends, there are no activities organized by the staff. Social work, physical rehabilitation, and medical treatment are available. As a part of the treatment, patients are expected to spend some weekends at home. The treatment is not highly structured and varies from one ward to another to some extent. The treatment period is variable but each patient is expected to stay for at least 6 weeks. Continuation of the treatment at local alcohol clinics or AA-meetings is recommended but no arrangements are made to this end.
Treoimcwt Aitcvzduncc, ond Trc.otmmi Drop-Oiiis Sixty-three (85. I %) of the patients randomized to Kalliola and 54 (80.6%) of the patients randomized to Jarvenpaa actually attended the institute. The remaining 24 patients ( 1 7.0%) were treatment refusers. Table 1. The Main
Variable Age f l SD Male Married Living with spouse Education
0145-6008/90/ I404-0584$2.00/0 Al.COllOl ISM: CI I h K ’ A I . A N I > E V P l K l h l t Y T A l RI.SI.AHCII
Inpatient Treatment of Employed Alcoholics: A Randomized Clinical Trial on Hazelden-Type and Traditional Treatment Lauri Keso and Mikko Salaspuro
The first randomized clinical trial on the Hazelden-type of treatment showed that this AA-oriented treatment for alcoholism can result in significant improvement in drinking behavior as compared to a more traditional form of treatment. One hundred forty-one employed alcoholics were randomized to either Hazelden-type treatment (N = 74) or to traditional-type treatment (N = 67). The treatment groups were highly comparable. The bimonthly follow-up lasted one year. According to the COPES-questionnaire(short form), the treatment at the Hazelden-type institute was significantly more involving, supportive, encouraging to spontaneity and oriented to personal problems than at the traditional-type institute. In accordance the treatment drop-out rate was 7.9% at Hazelden-type institute and 25.9% at traditional-type institute (p < 0.02). The participation in outpatient treatment was significantly better after the Hazelden-type treatment. The proportion of those abstinent (admitted ethanol consumption, 0 g/day; gammaglutamyl transferase, and mean cell volume were normal) was higher at Hazelden-type institute during the last (8-12 months) follow-up period (26.3% vs. 9.8%, p = 0.05). Fourteen percent of the Hazeldon-type institute patients and 1.9% of the traditional-type institute patients stayed abstinent during the whole 1-year follow-up period (p < 0.05). The differences for the corresponding rates for controlled drinking (admitted ethanol consumption less than 40 g/day, GGT, and MCV normal) were in the same direction but did not reach statistical significance. Thus the Hazelden-type treatment obtained better results in 1-year abstinence rate than a more traditional-type treatment. Key Words: Alcohol Dependency, Treatment, Clinical Trial
LCOHOLlSM IS THE major health problem among A employed population.’-4At present there are numerous different types of treatment available for alcoholics.’ Nevertheless convincing demonstration of their general efficiency is still lacking.’ On the contrary there is, for example, a major study showing no difference between treatment and “advice” (the “advice” consisted of one counseling session).‘ A new form of inpatient treatment, with strong ties to the AA-movement, has been developed in the Hazeldenclinic in Minnesota with claims for high recovery percentage among the patients.’-’ This Hazelden-type treatment has during the past spread throughout North America and
Scandinavia. Nevertheless controlled evaluations of its treatment results are lacking. The aim of our study was to compare the treatment results obtained by a Hazeldon-type treatment institute and the leading traditional-type treatment institute in Finland among employed alcoholics. PATIENTS AND METHODS The Puiicnrs Two hundred thirty-five employed alcoholics were sent to our outpatient clinic by their occupational health agency for the evaluation and direction to inpatient treatment. Ninety-one (38.7%)of them were not eligible for the study and thus were not randomized. The eligibility of the patients for the study was established in a I-hr long semistructured interview with a physician (who was one of the authors. LK). During the interview the patients’ social and medical history were covered as well as alcohol and drug use history. After the interview a detailed medical check-up was done. The exclusion criteria were the patients who ( I ) didn’t have serious problems with alcohol (didn’t meet the DSM-3 criteria for alcohol dependency), ( 2 ) refused either inpatient treatment or follow-up. (3) wanted to attend treatment in a specific institution, (4) were unable to fill the study questionnaires, (5) were a drug addict (i.e.. used or had used any illicit drugs ever), ( 6 ) were expected to be imprisoned during the follow-up period, (7) and whose state of health precluded normal life (long treatment period in a hospital was needed or patient suffered from serious brain damage or severe psychiatric illness). Almost all the exclusions were due to criteria 2 and 3 (58 and 32 patients. respectively). Fifty patients refused inpatient treatment but agreed to outpatient treatment in alcohol clinics. and eight patients refused all treatment. Altogether. 176 patients attended inpatient treatment and 8 I .8% (144) of these were randomized. Three patients were excluded from the analysis after the randomization. We were unable to include them to either treatment group since they did not attend the treatment they were randomized to but instead attended the other institute. Thus, the study group consisted of 141 patients. They were randomized (closed envelope method) to either Kalliola ( N= 74. Hazelden-type treatment) or Jarvenpaa ( N= 67. traditional-type treatment). The treatment groups were highly comparable with each other (Table I ) .
Thc Trwl men[ Ins1 it 111 P.S The treatment in Kalliola is based on the Minnesota (Hazelden)model. It treats only employed alcoholics. The center has 28 beds and a staff of 12 persons. The staff consists of a manager. a physician. a social therapist. a nurse, two therapists, four nonprofessional workers. a secretary. and a research worker. Eleven of the 12 staff members are active in AA. In accordance with the AA-principles. the basic aim of the treatment is to achieve enduring abstinence. To achieve this the rehabilitation . 4 h f i o / U r n E . Y Rns. ~ Vol 14. No 4. 1990: pp 584-589
585
INPATIENT TREATMENT OF EMPLOYED ALCOHOLICS center uses a highly structured treatment scheme which includes ( I ) lectures about alcohol physiology, (2) lectures with discussion about the mental structure of alcoholics and the alcoholic way of thinking, ( 3 ) the AA-program. (4) personal therapy, and (5) once a week group therapy sessions. The treatment period is 28 days. Each patient is introduced to an AA-member who helps the patient after the treatment period is over. With the help of this person, the patient is expected to start participating in the local AA-meetings. The treatment in Jarvenpaa has its foundations in the traditions of social work and psychiatric treatment. It gives treatment to all alcoholics (not only employed) and also to their families when necessary. Drug addicts are also treated. It has 168 beds and a staff of about 90 persons. Among them are three physicians (one of them. a specialist in psychiatry, is the manager of the institute), social therapists, psychiatric nurses, foremen, psychologists, a chaplain, a sports instructor, and offce workers, etc.. Members of AA are rare among the staff. The Institute consists of five wards (one of them for family treatment: however, none of the study patients were assigned to family treatment) in the main building, a smaller building for kindergarten, glass houses, cultivated grounds, work shops, sporting grounds, and room for various recreational activities. The aim of the treatment is the psychic, physical, and social rehabilitation of the addicts. Abstinence is recommended, but the specific treatment aims are worked out in co-operation with the patient. The main treatments used are ( I ) personal therapy, (2) various group therapy methods, (3) family therapy, and (4) work therapy. The patient receives at the most 8 hours of psychotherapy each week if work therapy is not included; in most instances less than that. During the working hours the patients are usually ( I ) working at work shops, cultivated grounds etc., (2) taking part in various sports, or ( 3 )thinking or reading in their rooms. One or two therapy sessions are included in daily activities. During the evenings and weekends, there are no activities organized by the staff. Social work, physical rehabilitation, and medical treatment are available. As a part of the treatment, patients are expected to spend some weekends at home. The treatment is not highly structured and varies from one ward to another to some extent. The treatment period is variable but each patient is expected to stay for at least 6 weeks. Continuation of the treatment at local alcohol clinics or AA-meetings is recommended but no arrangements are made to this end.
Treoimcwt Aitcvzduncc, ond Trc.otmmi Drop-Oiiis Sixty-three (85. I %) of the patients randomized to Kalliola and 54 (80.6%) of the patients randomized to Jarvenpaa actually attended the institute. The remaining 24 patients ( 1 7.0%) were treatment refusers. Table 1. The Main
Variable Age f l SD Male Married Living with spouse Education
