Journal of Consulting and Clinical Psychology 1977, Vol. 45, No. 2, 267-279

Integrated Behavior Change Techniques for Problem Drinkers in the Community Roger E. Vogler, Theodore A. Weissbach, and John V. Compton Pomona College

George T. Martin Mount San Antonio College Problem drinkers in the community were subjects in a study that evaluated the therapeutic potential of learning techniques in changing abusive drinking patterns and achieving moderation. The following procedures were studied: videotaped self-confrontation of drunken behavior, aversion training for overconsumption, discrimination training for blood alcohol concentration, alternatives training, behavior counseling, and alcohol education. All the techniques were applied to Group 1 (» = 23), the last four to Group 2 (« = 19), alcohol education only to Group 3 (n = 2 1 ) , and the last three to Group 4 (n = 17). During the first year of follow-up, significant decreases in alcohol intake were found for all groups, and the percentage of moderate drinkers changed from .0% to 62.5%. Significant differences between groups were not found. The effects on outcome of a large variance in pretreatment subject characteristics such as alcohol intake, as well as the amount of possible change in alcohol intake, the program's learning orientation, and blind follow-up are discussed as factors that may partially account for the lack of differential treatment effects. These issues are considered when comparing the results of this study with the results obtained in a similar study at Patton Hospital with chronic alcoholics. We conclude that moderation is a more attainable and feasible goal for problem drinkers than for chronic alcoholics. Evidence is mounting that drinking usually begins during adolescence and that social This project was supported by Grants 1 R18 AA-00489, 7 R18 AA-01197, and 1 R01 AA-01197 awarded by the National Institute on Alcohol Abuse and Alcoholism, Department of Health, Education, and Welfare, to the first author. We are grateful to the Department of Alcoholic Beverage Control of the State of California and the Wine and Spirits Wholesalers of Southern California who provided the variety of alcoholic beverages used in the research. We thank Herbert R. Dorken for his knowledgeable advice at the inception of this research. We appreciate the subject referrals made by Martin A. Hildreth, David C. Merriam, and Kenneth G. Ziebarth. We gratefully acknowledge the contributions to many phases of this research by the following persons: Jacqueline Berthon-Payon, Maureen Caddy, Susan Heath, Charmaine Hitchcox, Jean Kaida, Jay Knuppenburg, Patricia Rovan, Carol Shigetomi, Diane Temple, and Thomas Wiberg. Requests for reprints should be sent to Roger E. Vogler, Department of Psychology, Pomona College, Claremont, California 91711.

learning experiences are primary determinants of the onset and pattern of drinking (Cahalan, 1969, 1973; Jessor, Graves, Hanson, & Jessor, 1968; Jessor & Jessor, 197S). Such evidence has generated an increasing number of studies on alcohol from a learning point of view (e.g., Bourne & Fox, 1973; Eckert & Johnson, 1974). Several studies have focused on the effectiveness of a particular single technique in changing abusive drinking habits (e.g., Carrere, 19S4, 1958; Carrere, Craignou, & Pochard, 19S5; Lemere & Voegtlin, 1950; Vogler, Lunde, Johnson, & Martin, 1970). Others have manipulated discrete independent variables in the laboratory to measure their effects on specific parameters of drinking behavior (e.g., Bigelow, Cohen, Liebson, & Faillace, 1972; Bigelow & Liebson, 1972; Caudill & Marlatt, 1975; Griffiths, Bigelow, & Liebson, 1974; Mendelson, Mello, & Solomon, 1968; Nathan & O'Brien, 1971; Silverstein, Nathan, & Taylor, 1974). These studies

267

268

VOGLER, WEISSBACH, COMPTON, AND MARTIN

have generally avoided the criticism that most investigators "study alcoholics without alcohol or alcohol without alcoholics" ("Alcoholism: New Victims, New Treatment" 1974, p. 79). The studies have provided data on provocative theoretical issues, but none of these issues was studied in the natural environment. The studies that have had a more applied orientation (e.g., Hunt & Azrin, 1973; Lemere & Voegtlin, 1950; Lovibond & Caddy, 1970; Sobell & Sobell, 1972; Vogler et al., 1970) have generally been more optimistic in drawing conclusions about the promise of their treatment techniques than may be warranted. There are two reasons for considering their optimism unwarranted. First, most studies report only a few subject characteristics, yet two recent studies (Ruggels, Armor, Polich, Mothershead, & Stephen, 197S; Vogler, Compton, & Weissbach, 197S) have found that pretreatment subject characteristics can account for about 70% of the variance in treatment outcome. Second, the effectiveness of the techniques is difficult to evaluate because of methodological shortcomings such as an inexplicit description of experimental procedures (e.g., Lovibond & Caddy, 1970) or a lack of blind follow-up (e.g., Sobell & Sobell, 1972). Moreover, in the most comprehensive recent study evaluating treatment (Ruggels et al., 1975), two thirds of the abusers improved regardless of type of therapy. Thus, perhaps no treatment should be considered more promising than any other form of treatment without further evaluation. The current study was designed to remedy some of the above problems. The present study is similar to the one with chronic inpatient alcoholics at Patton Hospital (Vogler et al., 1975). However, the subjects in the present study were relatively intact problem drinkers (i.e., intact family, regularly employed, still maintain self-esteem, but with alcohol-related problems) living in the community. A multiple-component treatment package was studied to evaluate its potential effectiveness in reaching more drinkers in more ways, as compared with conventional, verbal approaches. In this research alcohol abuse was conceptualized as an acquired

habit (Vogler, Compton, & Weissbach, 1976). Six techniques were examined: video-taped self-confrontation of drunken behavior, discrimination training for blood alcohol concentration, aversion training for overconsumption, alcohol education, behavior counseling, and alternatives training. One group received all components, whereas three other groups received selected combinations. Thus, it was possible to compare the total package and one other combination involving drinking with two common treatments for alcohol abuse: counseling and education and education only. As in our previous study with chronic alcoholics, moderation rather than abstinence was the objective. We planned to test the feasibility of this goal for problem drinkers using these techniques. We also planned to identify possible predictors of success in treatment by examining the relationship between outcome data from follow-up and pretreatment data. Follow-up was conducted in the natural environment by persons unaware of the experimental design, hypotheses, or group assignment of subjects. Method Subjects The sample was composed of referrals from various community agencies and from newspaper advertisements 1 to the Behavior Research Center, Pomona, California, who met the following criteria: (a) at least 21 years of age; (b) could pass a medical examination to rule out health problems incompatible with the consumption of up to 16 ounces (473 ml) of 86-proof liquor or its equivalent; (c) no diagnosis of chronic brain syndrome or psychosis; (d) normal intelligence; (e) no history of felony assault; (f) not taking contraindicated medication (e.g., barbiturates, tranquilizers) at the time of the research; (g) never hospitalized for an alcohol problem or diagnosed by a health professional as an alcoholic; and (h) a current amount and/or pattern of alcohol intake sufficient to produce some legal, vocational, or marital problems. Of 409 referrals, 132 (32%) failed to meet one or more of the above criteria. One hundred thirteen (28%) failed to participate after their initial contact even though they were acceptable to the program.- Re1 "HEAVY DRINKERS wanted for federally sponsored research on new techniques to cut back your drinking." 2 Because many subjects were referred to us by

BEHAVIOR CHANGE TECHNIQUES FOR PROBLEM DRINKERS ferral data for 19 subjects were unavailable. Of the remaining 145 volunteer subjects, 103 (71%) were graduated, of which 13 were pilot subjects. Contact was lost with 10 graduates who were therefore not followed up, leaving a total of 80 subjects for analysis. The majority of subjects were referred as a result of the legal consequences of drinking, particularly drunk driving. Of the 409 referrals, 296 (72%) were court related, 51 (13%) responded to our newspaper advertisements, 26 (6%) were referred by health professionals, and the remaining 36 (9%) came from miscellaneous sources. The number of graduates from each referral source was proportional to the number referred. Of the 90 graduates, 73% (66 graduates) were court-related referrals, 12% (11) were newspaper respondents, 9% (8) came from health professionals, and 6% (5) came from miscellaneous sources. In addition to meeting the criteria listed above, we used the term problem drinker to refer to persons whose lives were relatively intact in some areas such as job, marriage, health, or self-respect. We were particularly interested in an increase in consumption of alcohol over time as an indication of a progressive habit. The specific characteristics of the 80 subjects used for the data analysis (23 in Group 1, 19 in Group 2, 21 in Group 3, 17 in Group 4) are presented in Table 1. The number of nonmatriculated dropouts (stopped attending before three sessions) for each group was as follows: Group 1, one; Group 2, two; Group 3, four; and Group 4, one. The distribution does not represent a significant departure from chance, X 2 (3) = 4.00, p > .25. The number of matriculated dropouts (i.e., failed to complete training after attending at least three sessions) for each group was as follows: Group 1, I S ; Group 2, 5; Group 3, 9; and Group 4, 5. The distribution does not differ significantly from chance, X 2 (3) = 7.7, p > .05.

Apparatus Sessions involving the consumption of alcohol took place in a simulated public bar setting that was equipped with video cameras and microphone, oneway mirror, and breath analysis devices. Offices were used for most nondrinking sessions. A complete description of the apparatus is presented in Vogler et al. (1975).

the court or by other legal agencies as a condition of probation, we believed there would be considerable coercion to serve as subjects in our project if no alternative were available (other than jail or a heavy fine). Therefore, all potential subjects were offered the option of participation in a variety of community treatment centers, which accounts for the loss of many of the 113 acceptable referrals who did not participate in this research.

269

Procedure After a full explanation of all of the procedures, written consent to participate was obtained from each volunteer. The subjects were then assigned randomly to one of four groups, except that an attempt was made to equalize the number of subjects in each group by referral source because the training of some groups started later than others, and the percentage of subjects from various referral sources changed somewhat over time. Groups 1 and 2 received learning techniques that involved the consumption of alcohol. Group 1 received all of the six components, which included videotaped self-confrontation of intoxicated behavior, discrimination training for blood alcohol level, aversion training for overconsumption, alcohol education, behavior counseling, and alternatives training. Group 2 received all of these techniques except the videotaped and aversion components. Group 3 received alcohol education only. Group 4 received alcohol education, behavior counseling, and alternatives training (see Table 2 ) . Subjects in Groups 1, 2, and 4 were scheduled for 34-40 contact hours; subjects in Group 3 were scheduled for 17-20 contact hours. For all groups, the first three sessions (6 hours) were the same: initial interviews, screening, and administration of personality tests. Some within-group variation in treatment time was observed (missed appointments, late for sessions, failure to terminate sessions on schedule, etc.), but as we reported previously (Vogler et al., 1975), no relationship was found between treatment time and outcome. The details of experimental procedures arc essentially the same as reported in the Patton study with chronic alcoholics. Differences in procedures were predicated upon two factors: (a) the hypothesized, relatively greater verbal ability of subjects in the present study and (b) the fact that all of the subjects were living at home and many were employed. They therefore had a greater range of activities and alternatives available to them than did the inpatient chronic alcoholics at Patton Hospital. Because of these differences, greater use was made of the verbal vehicles for effecting change: behavior conuseling, alternatives training, and alcohol education. Similarly, contingency contracting (Boudin, 1972; Hunt & Azrin, 1973) was used more extensively because of the greater community involvement of subjects. As compared with our earlier study, there were no baseline drinking sessions and no discriminated avoidance practice sessions, and except for the differences in emphasis noted above, the training was similar. The following is an abbreviated description of the sessions. Drinking history and assessment (all groups). The purpose of the first three sessions was to collect detailed information on demographic characteristics and pretreatment drinking information and to measure some personality attributes. Subjects were administered the California Psychological Inventory, the California Short-Form Test of Mental Maturity

VOGLER, WEISSBACH, COMPTON, AND MARTIN

270

(Level 5), the Crowne and Marlowe (1964) Social Desirability Scale, the Rotter (1966) Internal-External Locus of Control Scale, and an unpublished self-concept scale. Personal information relevant to subsequent counseling and education sessions was also recorded. Videotape recording and replay of intoxicated behavior (Group 1 only). Individual subjects consumed up to 16 ounces (473 ml) of 86-proof alcoholic beverage or its equivalent in 4-5 hours, sufficient to produce blood alcohol levels of 80 to 200 mg%. The purpose of the sessions was to obtain a good sample of changes in their behavior that would be stressful and induce a motivation to change when viewed in a subsequent replay session. After the replay session the tape was edited to include samples of sober and increasingly intoxicated behavior in a 20- to 30-minute tape. This shorter version was used in later sessions. Alcohol education (all groups). Groups 1, 2, and 4 received alcohol education training on an indi-

vidual basis. Some of the alcohol education material was presented to all subjects in an hour-long slidetape program developed specifically for this project. An alcohol education manual was also given to all subjects to prepare them for an examination. Group 3 subjects received alcohol education only to compare this very common form of community treatment for alcohol abuse with the other experimental packages under study. Some Group 3 sessions were conducted as group seminars. Information was presented about the effects of alcohol on the body and behavior along with some of the explanations for the development of abusive drinking habits but with emphasis on social learning explanations. The subjects were instructed in the use of the Alcocalculator (Alco-calculator, 1972; Compton & Vogler, 1975) to sensitize them to the relationship between consumption and levels of intoxication and impairment. Discrimination training for blood alcohol levels (Groups 1 and 2 ) . The discrimination training ses-

Table 1 Subjects' Pretreatment Characteristics Group Variable

1(23)

2(19)

3(21)

4(17)

Drinking data Intake" 94.50 Preferred beverage table wine Drinking companions strangers in bars Drinking environment homes of friends

Sex

Agcb Education1' Race Religion Social class"

81.11 fortified wine strangers in bars homes of friends

62.19 malt liquor strangers in bars homes of friends

79.00 table wine strangers in bars homes of friends

Demographic 19 males, 4 females 16 males, 3 females 18 males, 3 females 14 males, 3 females 35.35 35.86 39.17 39.26 11.88 11.81 13.17 14.16 20 Anglo, 3 Mexi- 16 Anglo, 2 black, 18 Anglo, 3 Mexi- 11 Anglo, 1 black, 5 Mexican can Americans can Americans 1 Mexican Americans American 8 Catholic, 10 3 Catholic, 11 5 Catholic, 7 Prot7 Catholic, 8 Protestant, 2 estant, 5 none Protestant, 4 Protestant, 4 none other, 5 none none IV III III IV Drinking related

No. jobs held last year 1.22 No. jobs lost by drinking .35 Alcohol-related arrests 2.26 Years of drinking problem 3.52 Drinking cycle 9 exc. social, 13 continuous, 1 binge Treated by Alcoholics Anonymous 4/23

1.16

1.42

1.35

.16 2.42

.05 2.52

.18 2.47

6.89

10 exc. social, 7 continuous, 2 binge

4/19

3.14 11 exc. social, continuous, binge 2/21

2.00 5 exc. social, 9 continuous, 3 binge 3/19

BEHAVIOR CHANGE TECHNIQUES FOR PROBLEM DRINKERS

271

Table 1—(Continued) Group Variable

1(23)

2(19)

3(21)

4(17)

Drinking related Self-evaluation Social drinker Excessive social drinker Constant drinker Binge/bout History of other drug use Marijuana Psychedelics Stimulants Depressants Heroin Alcohol substitutes Referral source Court related Mental health organization Newspaper Friend/former client Goal Abstinence Social drinking Moderate drinking Other

3

4

S

4

6 11 1

6 6 3

5 9

4 4

2

0

6

S 1 2 3 0 0

1

0 4 4 0 0

3 2 1 0 1

6 1 4 3 0 0

14

10

19

13

3 6

S 2

0 0

0 3

0

2

2

1

2 7 14 0

0 4

2 5 13 1

0 3 13 1

12

3

Note. Numbers in parentheses are ns. * Measured as absolute alcohol per month in ounces. b In years. c Classes III and IV represent the third and fourth classes from the top out of five classes (Hollingshead, Note 2). sions were conducted on an individual basis to teach subjects to discriminate increasing levels of intoxication so that they could reliably monitor their intake in the natural environment. Periodic breath analysis readings were taken to allow subjects to relate their blood alcohol readings to bodily sensations and other cues such as concentration of drinks, number of drinks, and consumption time. Although most subjects learned in two or three sessions with feedback to predict their blood alcohol level within 10 mg% of their actual concentration, additional training was provided in subsequent sessions. Averswn training for overconsumption (Group 1 only). The purpose of the aversion training sessions was to draw the subject's attention to the cues related to consumption above the SO mg% level. When a subject reached a blood alcohol concentration in excess of SO mg%, he was connected with finger electrodes and shocked 8-10 times over the next 30 to 45 minutes. Three to six milliamp shocks were delivered when the subject sipped or smelled his drink, and the shocks were often accompanied by statements made by the trainer in-

tended to induce thoughts about situations in which the subject had typically overindulged, Behavior counseling and alternatives training (Groups 1, 2, and 4 ) . The main purpose of the behavior counseling sessions was to aid subjects in handling situations related to their drinking. This often involved the use of assertion training or problem-solving techniques. Sometimes personal problems of a more serious nature were dealt with but usually not in depth. Alternatives training involved instruction and guidance in developing recreational Qr avocationa] activities that would compete with drink;

.

.

Typicallyi a subject , g daily schedulc was

, . . ,, ., ,. , ° detcrmlne thosc situations and setting xcessive e drawing for which an alternative could bc Planned and implemented. Sometimes tnc cooperation of a spouse or other significant person was solicited with whom a contingency contract was made. The purpose of contracting was to initiate changes in behavior in high-risk drinking situations that could be maintained by natural contingencies.

analyzed l events for

VOGLER, WEISSBACH, COMPTON, AND MARTIN

272

Wrap-up (all groups). A review of problems and their solutions as well as a replay of the edited videotape (Group 1 only) constituted the final training session. Subjects were told of the first booster session and to contact us regarding any significant changes in their behavior. They were also reminded that a field representative would contact them on a monthly basis. Booster sessions (Groups 1, 2, 4 ) . Components of the treatment were administered at each of 13 sessions (2 the first month and 1 per month each month thereafter). The purpose of the booster sessions was to prolong the effects of training while providing a continuous reliability check on intake and related data concurrently being collected by the experimentally blind follow-up person. When noted, discrepancies between subjects' verbal followup and booster session data were cither resolved or the questionable data were discarded. Group .\ (alcohol education only) did not receive booster sessions in order to provide a comparison with this common form of treatment for alcohol abuse in the community, which does not provide booster sessions. Follow-up (all groups). The follow-up procedure consisted of structured interviews of subjects in the natural environment by a single field representative blind to group assignments and to the details of the study. 3 During the final (wrap-up) session of treatment, subjects were reminded that a field representative would contact them monthly to collect data on their drinking and drinking-related behaviors. The subjects were also reminded of the research nature of the project and were urged to report honestly all drinking behavior. Data collected included information on amount and pattern of drinking as well as social and vocational adjustment. The interview schedule was designed to reduce response bias as much as possible by stating questions in a neutral way (e.g., "How much did you

Table 2 Distribution of Techniques Across Groups

Table 3 Distribution of Abstinent, Controlled, and Relapsed Subjects by Treatment Group Group

Abstinent

Controlled

1

2

14

2

0 1 0

13 12 11

3

4

Relapsed

7 6 8 6

drink last month?" as opposed to "Did the amount you drank last month change from the month before?"). The interviewer was trained to be alert to inconsistencies in responses and to probe to resolve them (e.g., "I drank one six pack of beer" and "I spent $10 on alcoholic beverages"). When responses were obviously inconsistent, the interviewer would attempt to contact a collateral source familiar with the subject's current drinking pattern. Collaterals were contacted only if the subject gave permission to do so in order to avoid the loss of the subject's cooperation. Occasionally subjects' spouses or significant others were present during interviews. The objective was to contact each subject on a monthly basis, and interviews were arranged at the subject's convenience in his home, at work, or at a public meeting place. Drunk driving records from the Department of Motor Vehicles and correspondence with court officials were used to validate follow-up reports.

Results We were attempting to answer three basic questions: (a) Can problem drinkers achieve moderation? (b) Do different combinations of treatment differ in their effectiveness? and (c) Can treatment success be predicted better from treatment modality or from subject characteristics?

Group Procedure Pretraining Initial interview Medical exam Drinking history Wet training Videotape and replay Blood alcohol concentration discrimination Aversion training

1(23) X X X

2(19) 3(21) 4(17) X X X

X X X

X X X

X

X

X X

X

X X

X

X

Dry training

Behavior counseling/ alternatives training Alcohol education Posttraining Wrap- tip Kollow-up Boosters

X X X X X

Note. Numbers in parentheses are MS.

X X

X X

X

Evaluation of Treatment

Effectiveness

The treatment goal stated to subjects was moderation. The criteria for classifying a subject as a moderate drinker were (a) intake of less than SO ounces (1,479 ml) of absolute alcohol per month and (b) no more than one drinking episode per month during which

X

X X

3 The follow-up person remained ignorant of the group assignment of subjects and therefore the combination of techniques subjects received, but he did become familiar with certain procedures used in the research.

BEHAVIOR CHANGE TECHNIQUES FOR PROBLEM DRINKERS I'"""I

i'UK ]'lihA I MEN f

^^H

PO,S I I K!-,AI MKN 1

1 Figure 1. Distribution of intake prior to and after treatment.

the blood alcohol concentration exceeded 80 mg% over the 12-month follow-up period. These criteria were used because they take into consideration both pattern and amount of drinking so that, for example, even a subject who drinks "only" 20 ounces (592 ml) of absolute alcohol would still be considered an abuser if all 20 ounces were consumed in one or two sittings. Using these criteria, 50 of 80 subjects were moderate drinkers. An additional three subjects were abstinent. Thus, 53 out of 80 subjects (66%) could be considered successes (see Table 3). However, despite the fact that all subjects reported a drinking problem prior to treatment, the range of reported monthly intake was quite broad. Many subjects did not report a large monthly intake to begin with (see Table

273

4 and Figure 1). Their problem was one of distributing their intake better rather than reducing it substantially; that is, they did not meet the second criterion above for moderation. None of the subjects met both criteria for moderate drinking prior to treatment. Another way in which the question of success can be answered is to examine changes in specific drinking and drinking-related behaviors after treatment. Five measures of pretreatment-posttreatment differences were examined to answer this question: intake in ounces of absolute alcohol, preferred beverage, drinking companions, drinking environment, and number of clays per month lost from work because of drinking. Ordinal scales were constructed for the measurement of preferred beverage, drinking companions, and drinking environment. For preferred beverage, the order was determined by the alcohol content of the beverage. A low score indicated low alcohol content. The range of scores was 1-7. For drinking companions, the order was determined by the probability that the specified companions would encourage social drinking or abstinence rather than overconsumption. The lower end of the scale was anchored by family, the upper end by drinking alone (range = 1-5). For drinking environment, the scale reflected the probability that different drinking locales would lead to moderation or abstinence rather than overconsumption. The lower end of the scale was represented by

Table 4 Number of Subjects in Seven Intake Categories Before and After Treatment Posttreatment intake category" Pretreatmcnt intake category" 0 1-25 26-50 51-75 76-100 101-200 201 +

Posttreatraent ns by category

0 11

16 20 12 18 3

2 1

3

26-50

9 8 9 4 2

2 5 10 2 6 1

2

26

10

32

Note. 1 ounce = 30 milliliters. Measured in ounces of absolute alcohol per month.

0

51-75

1-25

76-100

101-200

201 +

1

1 2 5

2 1

2 3

4

5

0

274

VOGLER, WEISSBACH, COMPTON, AND MARTIN

drinking at the homes of friends or in one's own home, and the upper end of the scale was anchored by transient locales (alleys and parking lots, e.g.). The range was 1-6. Multivariate parametric techniques were used with ordinal data to avoid the contamination of alpha level that may result from the use of multiple statistical tests on related dependent variables. However, nonparametric test results are also reported. An estimate provided by the subjects prior to beginning treatment and prior to group assignment on each 01 the five measures was compared to 6-month and 12-month follow-up data collected by the independent field representative (see Table 5). The mean number of subjects followed up per month was 33. The average number of monthly follow-ups per subject over the 12-month period was 4.86. The treatment groups did not differ significantly in the number of follow-ups per subject. The difference in the mean number of follow-ups for relapsed (M = 5.26) versus controlled/abstinent subjects (M = 4.66) was not significant, £(78) = 1.00. The five dependent variables were subjected to a multivariate analysis of variance (University of Miami Biometric Laboratory, Note 1). Because of the large pretreatment

differences in alcohol intake between groups, these scores were adjusted to yield residual gain scores. A residual gain score is a difference, or gain, score corrected for error of measurement, for regression of initial scores on retest scores, and for initial between-groups differences (Lord, 19S6). These adjusted posttreatment intake scores were used in all analyses on alcohol intake. The results of the multivariate analysis of variance of the five criterion variables (see Table 6) indicated that there was a significant overall between-groups effect that can be accounted for largely by the significant between-groups effect for preferred beverage and drinking companions. However, this effect must be attributed to differences on these variables that existed prior to treatment rather than to a differential treatment effect. There was also a significant overall prepost change; three of the five dependent variables—intake, drinking companions, and drinking environment—showed a significant change. None of the interactions was significant. Alcohol Intake At the 6- and 12-month follow-up intake levels, the average subject in all four condi-

Table S Means of Criterion Variables Group

Intake

Beverage

Companions

Environment

Days lost

1(23) Pretreatment 6 months 12 months

94.48 34.21 34.40

3.96 3.55 3.56

3.09 2.60 2.22

3.13 2.47 2.20

.26 .08 .03

2(19) Pretreatment 6 months 12 months

81.11 34.66 39.31

4.53 4.08 3.90

3.21 2.92 2.77

2.68 2.86 2.37

.26 .21 .12

3(21) Pretreatment 6 months 12 months

62.19 36.06 25.88

3.29 2.89 2.46

3.43 3.26 2.72

2.67 2.46 2.01

.10 .17 .00

4(17) Pretreatment 6 months 12 months

79.00 41.43 42.01

3.94 3.55 4.09

3.18 2.98 3.01

2.71 2.52 2.72

.29 .00 .03

Note. Numbers in parentheses are ns.

BEHAVIOR CHANGE TECHNIQUES FOR PROBLEM DRINKERS

tions was consuming the equivalent of approximately three 1-ounce (88 ml) drinks of 86-proof beverage per day or about 3.5 gallons (13.25 liters) of absolute alcohol per year. Using the most conservative pretreatment estimate of intake, the reduction in intake was equivalent to 30 ounces (885 ml) of absolute alcohol per month or from five to three drinks of 86-proof beverage per clay and from 6 gallons (22.71 liters) to 3.5 gallons (13.25 liters) per year. The Group 1 decline of approximately 50 ounces per month of absolute alcohol was greater than for the other three groups. This represents a decline of from seven to three drinks per day and from 8.25 gallons (31.23 liters) to 3.5 gallons (13.25 liters) per year. Preferred Beverage, Drinking Companions, and Drinking Environment Although the multivariate analysis of variance indicated a significant improvement in drinking companions and drinking environment, an examination of the proportion of subjects in each group that improved indicated that only Groups 1 and 3 showed significant improvement and only for drinking companions (see Table 7 ) . The improvement was found at both the 6- and 12-month follow-up for Group 1 but at 12 months only for Group 3. Other Dependent Variables Examination of eight other criterion variables for which data were available revealed no significant differences between groups. These variables are drinking pattern, hours spent drinking, amount spent on alcohol, number of days drinking, number of days that drinking was controlled, number of days drunk, job status, and monthly salary. Relationship of Subject Characteristics to Treatment Outcome Two approaches were used to evaluate the relationship between subject characteristics and outcome: multiple regression and discriminant analysis. In the multiple regression analysis, five criterion variables were pre-

275

Table 6 Multivariate Analysis of Variance Source

MS

2.05 .011 Between groups 15, 619 Intake 3, 228 2,340.15 1.20 .312 18.43 5.07 .002 Beverage Companions 3.20 2.89 .036 .95 1.13 .339 Environment .13 .42 .738 Days lost 10, 448 6.82 .001 Pre-post 2, 228 51,421.69 26.30 .001 Intake 4.93 1.36 .260 Beverage Companions 6.62 5.98 .003 5.27 6.22 .002 Environment .68 2.14 .120 Days lost 30, 898 Interaction .76 .820 6, 228 2,090.48 1.07 .380 Intake 1.16 .32 .926 Beverage Companions .84 .76 .606 1.54 1.81 .098 Environment .12 .38 .894 Days lost

dieted separately from pretreatment subject characteristics. The five criterion variables were posttreatment measures of intake, preferred beverage, drinking companions, and drinking environment, as well as whether the subject was classified as abstinent, controlled, or relapsed. The subject characteristics included pretreatment measures of the criterion variables, demographic characteristics, arrest records, self-evaluation of drinking problem, and personality test results. For the discriminant analysis, all subjects were combined into two categories: (a) abstaining or controlled and (b) relapsed (see data in Table 3). Only three variables significantly discriminated between the two categories: pretreatment intake, pretreatment drinking companions, and age. In the first two cases the direction of the difference was in favor of the successful subjects; they drank significantly less prior to treatment and drank with companions more likely to encourage moderate drinking. In the last case, successful subjects were older than relapsed subjects. Using these three variables alone, 80% of the subjects could be correctly categorized on the basis of pretreatment characteristics as successes (controlled or abstinent) or failures (relapsed). The results of the multiple regression analyses were not consistent. The five cri-

276

VOGLER, WEISSBACH, COMPTON, AND MARTIN

Table 7 Frequency of Change in Drinking-Relaled Behaviors for Three Criterion Variables 6 months Group

Lower

x2

Higher

Alcohol content of preferred beverage 1(23) 7 3 2(19) 6 2 3(21) 4 4 4 4(17) 3 Drinking companions 1 2 3 4 Drinking environment 1 2 3 4

12 months Lower

1.60 2.00 .00 .14

7 8 8 5

Better

Worse

11

2 6 8 8

6.23** 1.00 .07 1.33

12 9 9 3

4 5 8 1

2.57 .09 .69 2.67

10 9 13 5

3

7 4 10 6

5 5

Better

Higher

x2

6 5 6

.85 .69 .29 .11

4 Worse

5.40* .25 4.45* 3.00

4 6 6 4

2.57 .60 2.58 .11

Note. All chi-squares are for correlated proportions. MS are in parentheses. * p < .05. *** < .02.

terion variables described earlier (alcohol intake, preferred beverage, drinking companions, drinking environment, and clays lost from work) were each predicted from pretreatment characteristics. These subject characteristics included pretreatment measures of the criterion variables, personality measures, demographic characteristics, and other data related to drinking history. In the case of four of the five criterion variables (the exception was days lost from work), the best predictor was its own pretreatment measure. For example, the best predictor of alcohol intake during follow-up was pretreatment intake. No consistent set of predictors was found for all of the criterion variables. Discussion The data indicate that most problem drinkers can learn to reduce their alcohol intake and/or to redistribute it to minimize the number of episodes of excessive use. Although none of the subjects was drinking moderately according to one or both of the criteria before

treatment, 62.5% could be classified as moderate and 4% were abstinent during the 1 year after treatment. Each combination of techniques studied was effective in significantly reducing intake and in improving drinking environment and companions. There were no statistically significant advantages to one set of techniques over the others. Although this finding is in accord with the Stanford Research Institute report (Ruggels et al., 197S), there are several possible factors that may have influenced this outcome. Experimenter-bias effects and the validity of subjects' verbal reports are powerful confounds that may contribute to the finding of group differences in other field research. However, blind follow-up in the natural environment, multiple contacts over the year, the use of a questionnaire sensitive to discrepant information, and other sources of collateral data reduced such bias in the present study. Perhaps the strong emphasis on drinking as learned and modifiable behavior and on moderation as an attainable goal, which was common to all groups, were important determinants of change. The sig-

BEHAVIOR CHANGE TECHNIQUES FOR PROBLEM DRINKERS

nificant improvements in the chronic alcoholics who served as controls in the Patton study may also be attributable in part to the learning orientation. However, the chronic alcoholic experimental subjects at Patton did improve significantly more than the controls, which was not the case in the present study with problem drinkers, although the absolute change in alcohol intake was greater for Group 1 than for the other groups. This difference in the outcome of the two studies may be because the potential drop in intake was twice as great for the chronic alcoholics (average consumption at pretreatment was 14.8 gallons [56 liters| per subject per year for the chronic alcoholics as compared with 7.5 gallons [28 liters] per subject per year for the problem drinkers). The limited range to reflect changes may therefore be largely responsible for the failure to obtain significant group differences in the problem drinker study. The results of the alcoholic and problem drinker studies are similar in that pretreatment subject characteristics accounted for about 70% of the outcome variance, leaving little between-group variance to be influenced by differences in therapeutic techniques. This finding is in accord with the survey of treatment outcome reported by the Stanford Research Institute (Ruggels et al., 1975). The problem of obtaining between-group effects is exacerbated by sampling problems. We had considerable difficulty in obtaining a sufficient number of subject referrals (Vogler et al., 1976). Therefore, we could not restrict arbitrarily the range of pretreatment subject characteristics. Field studies such as the present one may use subject populations that are more heterogenous than laboratory or nonclinical studies. On the other hand, wide variation in pretreatment subject characteristics increases the size of correlations between these variables and outcome. This means that pretreatment subject characteristics are more likely to be identified as significant predictors of outcome and to account for a large proportion of the outcome variance. As in the Patton study, there was evidence that pretreatment subject characteristics can be used to predict treatment success.

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Pretreatment alcohol intake was again the best predictor of whether or not a subject can improve and successfully achieve moderation. We reported elsewhere (Weissbach, Vogler, & Compton, 1976) that scores on Rotter's (1966) Internal-External Locus of Control Scale did not correlate significantly with pretreatment measures of alcohol intake or with reduction in alcohol consumption. Similarly, the other personality measures administered to subjects in this study were not related to treatment outcome. These findings are in accord with Bandura's (1969, pp. 528-529) summary of the research on personality factors and alcoholism. Perhaps the greatest difficulty with this research is the heavy reliance on self-report data from problem drinkers. Neither the reliability nor the validity of the data can be known with certainty. In addition to the suspicion that problem drinkers might not be completely honest about reporting their drinking, the research design (treatment for problem drinking) carried strong demand characteristics to report a decline in drinking. We were well aware of these problems, and we made a conscious choice to proceed in the manner described because we were unable to devise any reasonable alternatives. Demand characteristics were constantly played down to subjects. The empirical nature of the project was stressed repeatedly. Subjects were told that we were making a sincere effort to evaluate objectively the effectiveness of different treatments, that we were not committed to their success, that we honestly wanted to know if the treatments did not work, and so on. The field representative was represented as an independent evaluator with no commitment to the project's success (which was true). The follow-up questionnaire was designed to reduce the probability that subjects would give responses that indicated treatment success and to provide internal checks on the reliability of subjects' responses. What alternative methods of measurement might have been used? Subjects' drinking behavior might have been measured in the laboratory. However, even if laboratory con-

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ditions could be arranged so that subjects could drink "naturally" (Miller & Hersen, 1972; Miller, Hersen, & Eisler, 1974), one still has the problem of determining the correlation between behavior in the laboratory and behavior in the natural environment. Could subjects be monitored in the natural environment so that self-report would be unnecessary? It is possible but not very feasible. For example, one could make unannounced visits with a breath analysis device to check blood alcohol level. However, we would not expect most subjects to consent to unannounced visits, and even if they did, many might terminate their participation after a few visits. Moreover, several visits would be necessary to obtain a fairly valid index of the subjects' drinking behavior. Or, someone (a family member) could be assigned to watch the subject and report his/her drinking behavior, or an employer might be asked to report on work efficiency, days lost from work, and so forth. However, both of these alternatives raise the same problems of consent and validity as do unannounced visits. We speculate that pretreatment intake differences between the chronic alcoholics at Patton and the problem drinkers in this study may account for differences in the number of abstinent subjects during the first 12 months of follow-up. We found that only 3 (4%) of the problem drinkers as compared to 14 (33%) of the chronic alcoholics were abstinent during the first year of follow-up. Since the initial intake of the chronic alcoholics was twice as great as that of the problem drinkers, we infer a higher physiological tolerance for the intoxicating effects of alcohol for the chronic alcoholics as well. This higher physiological tolerance to alcohol would prevent the chronic alcoholic from experiencing any of the reinforcing effects of consumption at moderate blood alcohol levels. Thus, moderation would not be satisfying to him, and he may as well not drink at all as to drink moderately. We hypothesize that in order to learn to become a moderate drinker, the tolerance threshold for the intoxicating effects of alcohol should be below SO mg% blood alcohol. Of course, this hypothesis does not apply to those chronic alcoholics whose

drinking has caused sufficient physical pathology to induce a reverse tolerance effect (Jellinek, 1960). For these drinkers and others with a high tolerance to alcohol, abstinence is probably a more suitable treatment objective. Conversely, problem drinkers in this study who began treatment with half the intake of the chronic alcoholics, and with a presumably lower tolerance for the intoxicating effects of alcohol, were more than twice as likely to become moderate drinkers. Therefore, we conclude that moderation is a more appropriate treatment goal for problem drinkers than it is for chronic alcoholics. We believe it is important to determine the relationship between alcohol intake history and the threshold for perceiving intoxicating effects to determine whether discrimination training is possible and whether moderation is a feasible therapy goal for any particular drinker. A clarification of the relationship between intake history and threshold will also provide objective and quantifiable diagnostic information. That is, we may find that the higher the tolerance threshold, the greater the existing or potential drinking problem. Reference Notes 1. University of Miami Biometric Laboratory. Multivariate analysis of variance. Unpublished manuscript, no date. 2. Hollingshead, A. B. Two-factor index of social position. Unpublished manuscript, Yale University, 1957.

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Received May 3, 1976 •