Individualized Behavior Therapy for Alcoholics - Republished Article.

A behavior therapy for alcoholism was designed based on the rationale that alcoholic drinking is a discriminated, operant response. Treatment emphasized determining setting events for each subject's drinking and training equally effective alternative responses to those situations. Seventy male, hospitalized, Gamma alcoholics were assigned to a treatment goal of either nondrinking (N=30) or controlled drinking (N=40). Subjects of each group were then randomly assigned to either an experimental group receiving 17 behavioral treatment sessions or a control group receiving only conventional treatment. Treatment of experimental groups differed only in drinking behaviors allowed during sessions and electric shock avoidance schedules. Nondrinker experimental subjects shaped to abstinence, while controlled drinker experimental subjects practiced appropriate drinking behaviors with little shaping, a result attributed to instructions. Follow-up measuring drinking and other behaviors found that experimental subjects functioned significantly better after discharge than control subjects, regardless of treatment goal. Successful experimental subjects could apply treatment principles to setting events not considered during treatment, suggesting the occurrence of rule learning. Results are discussed as evidence that some "alcoholics" can acquire and maintain controlled drinking behaviors. Traditional treatment of alcoholics may be handicapped by unvalidated beliefs concerning the nature of the disorder.

Continuities and changes in self-change research.

AIMS: A substantial literature demonstrates that natural recoveries from substance use disorders not only occur but are a common pathway to recovery. This article reviews selectively and comments on the current state-of-the-art in natural recovery research. METHODS: Basic concepts in natural recovery research are presented, and topical and methodological trends and changes in self-change research over time are discussed. CONCLUSIONS: Although considerable progress has occurred in natural recovery research, several topics deserving of further research are identified, and implications for policy practice are discussed.

Family medicine residents' beliefs, attitudes and performance with problem drinkers: a survey and simulated patient study.

Fifty-six second-year family medicine residents completed a survey on their knowledge and beliefs about problem drinkers. Most residents felt responsible for screening and counseling, were confident in their clinical skills in these areas, and scored well on related knowledge questions. However, only 18% felt that problem drinkers would often respond to brief counseling sessions with physicians while 36% felt that moderate drinking was a reasonable goal for patients with severe alcohol dependence. Residents were then visited by unannounced simulated patients (SPs) presenting with alcohol-induced hypertension or insomnia. Residents detected the SP in 45 out of 104 visits. In the 59 undetected SP visits, residents asked about alcohol consumption in 47 visits (80%), discussed the relationship between alcohol use and the presenting complaint in 37 visits (63%), and recommended a specific weekly consumption in 35 visits (59%). Only 31% offered reduced drinking strategies, and most did not ask about features of alcohol dependence. These results suggest that residents have the fundamental clinical skills required to manage the problem drinker who gives a clear history and is receptive to advice. Educational efforts with residents should focus on the importance of systematic screening, taking an alcohol history under more challenging conditions, identifying the subtler presentations of alcohol problems, counselling the less receptive patient at an earlier stage of change, distinguishing the problem drinker from the alcohol-dependent patient, and offering specific behavioral strategies for the problem drinker.

Family Medicine Residents' Performance with Detected Versus Undetected Simulated Patients Posing as Problem Drinkers.

BACKGROUND: Simulated patients are commonly used to evaluate medical trainees. Unannounced simulated patients provide an accurate measure of physician performance. PURPOSE: To determine the effects of detection of SPs on physician performance, and identify factors leading to detection. METHODS: Fixty-six family medicine residents were each visited by two unannounced simulated patients presenting with alcohol-induced hypertension or insomnia. Residents were then surveyed on their detection of SPs. RESULTS: SPs were detected on 45 out of 104 visits. Inner city clinics had higher detection rates than middle class clinics. Residents' checklist and global rating scores were substantially higher on detected than undetected visits, for both between-subject and within-subject comparisons. The most common reasons for detection concerned SP demographics and behaviour; the SP "did not act like a drinker" and was of a different social class than the typical clinic patient. CONCLUSIONS: Multi-clinic studies involving residents experienced with SPs should ensure that the SP role and behavior conform to physician expectations and the demographics of the clinic. SP station testing does not accurately reflect physicians' actual clinical behavior and should not be relied on as the primary method of evaluation. The study also suggests that physicians' poor performance in identifying and managing alcohol problems is not entirely due to lack of skill, as they demonstrated greater clinical skills when they became aware that they were being evaluated. Physicians' clinical priorities, sense of responsibility and other attitudinal determinants of their behavior should be addressed when training physicians on the management of alcohol problems.

Nondaily drinkers score higher on the Alcohol Dependence Scale than daily drinkers.

To evaluate the relationship between drinking pattern and alcohol dependence severity, 209 individuals voluntarily seeking treatment for alcohol problems were administered the Alcohol Dependence Scale (ADS), the Short Alcohol Dependence Data (SADD) questionnaire, and a 12-month Timeline Follow-Back (TLFB) drinking assessment as part of their pretreatment assessment. Based on their TLFB data, participants were divided into two groups: daily (DD, n=84) and nondaily (NDD, n=125) drinkers. The two groups were compared on several demographic and drinking variables. It was hypothesized that DD would have higher scores on measures of alcohol dependence than NDD. However, the reverse pattern was found. The NDD had significantly higher ADS scores than the DD. An analysis of ADS subscale scores indicated that the primary difference between the two groups was in the domain of loss of behavior control. It is suggested that NDD may perceive intoxication as more impairing, perhaps because they have acquired less tolerance than DD. These results suggest that treatment focused on restoring a sense of behavior control would be beneficial for NDD.

What do Internet-based alcohol treatment websites offer?

The Internet was searched for websites that advertised or provided treatment or help for alcohol problems. Websites were evaluated for the types of treatment offered and whether the treatment had an empirical basis. While a wide range of treatments were advertised, very few websites offered online services. In addition, very few sites provided or advertised alcohol treatment programs that were empirically based. Recommendations for future Internet-based health care and treatment are offered.

Drug treatment outcome methodology (1993-1997) strengths, weaknesses, and a comparison to the alcohol field.

Although several critiques of the methodology of alcohol treatment outcome studies have been published, similar reviews of the methodology of drug treatment outcome studies are lacking. This paper reviews the methodology of drug treatment outcome studies published from 1993 through 1997 and draws comparisons with the most recent methodological review of alcohol treatment outcome studies. Each drug study was evaluated as to whether the following types of data were reported: (1) demographic, (2) drug use, (3) study characteristics, and (4) outcome and follow-up information. Although results for drug studies showed some areas of strength compared to alcohol studies, in general, the weaknesses were similar to or worse than in the alcohol field, including inadequate reporting of demographic and drug use variables. Weaknesses in follow-up procedures were particularly notable. Suggestions for improving the reporting of methodological and outcome variables for drug treatment outcome studies are discussed.

Physician behavior towards male and female problem drinkers: a controlled study using simulated patients.

BACKGROUND: Evidence suggests that physicians are less likely to identify alcohol problems in females than in males. PURPOSE: To compare the performance of family medicine residents with male and female simulated patients (SPs) posing as problem drinkers. METHODS: Fifty-six family medicine residents completed a baseline survey on knowledge and attitudes towards problem drinkers. Each resident was then visited by one male and female unannounced SP. The male and female roles were similar with respect to presenting complaint (in somnia or hypertension), age, social class, and drinking history. RESULTS: Residents expressed slightly more positive attitudes towards female than male patients (3.32 vs. 3.09, p < .001). Residents scored higher with undetected male than with undetected female SPs on the assessment checklist (5.1 vs. 3.2, p < .045), the management checklist (4.4 vs. 3.2, p = .032), and an interpersonal rating scale (the Alcohol Skills Rating Form; 5.5 vs. 4.7, p = .023). CONCLUSION: Educational programs should focus on improving physicians' clinical skills in the identification and treatment of alcohol problems in women.

Alcohol Abuse and Smoking: Dual Recoveries.

Between 80 and 95 percent of all alcohol abusers smoke cigarettes, leading to enormous public health problems. Little is known, however, about how changes in drinking and/or smoking affect recovery from both of these problems. A long-term study of alcohol abusers who also had been smokers at some point in their lives found that most of these people had recovered from both alcohol abuse and smoking and that these recoveries were very stable. Continued smoking, however, generally was associated with an increased risk for relapse to alcohol abuse.