Couples relapse prevention sessions after behavioral marital therapy for male alcoholics: outcomes during the three years after starting treatment.

OBJECTIVE: This article provides a complete report of outcome data from a study of behavioral marital therapy (BMT) with and without additional couples relapse prevention (RP) sessions. (See J. Stud. Alcohol 54: 652-666, 1993, for an earlier partial report.) METHOD: Fifty-nine couples with an alcoholic husband, after receiving weekly BMT couples sessions for 5-6 months, were assigned randomly to get or not get 15 additional couples relapse prevention (RP) sessions over the next 12 months. Outcome measures were collected before and after BMT and at quarterly intervals for the 30 months after BMT. RESULTS: BMT-plus-RP produced more days abstinent and greater use of the Antabuse Contract than BMT-only; and these superior drinking outcomes for BMT-plus-RP lasted through 18-month follow-up (i.e., 6 months after the end of RP). BMT-plus-RP had better wives' marital adjustment than BMT-only throughout the 30 months of follow-up, with the superiority of BMT-plus-RP over BMT-only being greatest for wives with poorer pretreatment marital adjustment during the later months of follow-up. BMT-plus-RP also maintained their improved marriages longer (through 24-month follow-up) than BMT-only (through 12-month follow-up). Irrespective of treatment condition, more use of BMT-targeted marital behaviors (e.g., shared recreational activities, constructive communication) was associated with better marital and drinking outcomes throughout the 30-month follow-up period whereas more use of the Antabuse contract was associated with better marital and drinking outcomes through 12-month follow-up. Alcoholics with more severe marital problems had more abstinent days and maintained relatively stable levels of abstinence if they received BMT-plus-RP, while their counterparts who received BMT-only had fewer abstinent days and showed a steep decline in abstinent days during the 30 months of follow-up. Furthermore, alcoholics with more severe alcohol problems used the Antabuse contract more and showed a less steep decline in use of the Antabuse contract in the 30 months of follow-up if they received BMT-plus-RP than if they received BMT-only. CONCLUSIONS: For the entire sample, BMT-plus-RP produced better marital outcomes throughout the 30 months of follow-up and better drinking outcomes during and for the 6 months following RP sessions, relative to BMT-only outcomes. For alcoholics with more severe marital and drinking problems, BMT-plus-RP produced better drinking outcomes than BMT-only throughout the 30-month follow-up period.

Sexual satisfaction and dysfunction in marriages of male alcoholics: comparison with nonalcoholic maritally conflicted and nonconflicted couples.

OBJECTIVE: This study examined the contribution of alcoholism and marital conflict to male alcoholics' sexual problems. METHOD: Married couples with an alcoholic husband (n = 26) were compared with 26 maritally conflicted and 26 nonconflicted couples without alcohol-related problems on both sexual dysfunction and sexual satisfaction. RESULTS: The male alcoholics and their wives experienced less sexual satisfaction across a range of variables and more sexual dysfunction-specifically husbands' diminished sexual interest, impotence and premature ejaculation, and wives' painful intercourse-than nonconflicted couples. However, impotence was the only aspect on which alcoholics reported more difficulties than did maritally conflicted couples. When husbands' age was considered, more frequent retarded ejaculation with older age was unique to the alcoholics since it did not occur in conflicted or nonconflicted husbands; and there was a greater decline in frequency of intercourse with older age among the alcoholic than among the conflicted couples. CONCLUSIONS: These findings are consistent with a biopsychosocial formulation of alcoholics' sexual adjustment problems that implicates (1) marital conflict as a major contributing factor to most of these problems and (2) the combined role of both marital conflict and the physical effects of chronic alcohol abuse as most relevant to the elevated rates of impotence and retarded ejaculation (among older alcoholics) and the steeper decline in intercourse frequency with age.

Cost-benefit and cost-effectiveness analyses of behavioral marital therapy as an addition to outpatient alcoholism treatment.

Thirty-six newly abstinent married male alcoholics, who had recently begun outpatient individual alcoholism counseling, were randomly assigned to a no-marital-therapy control group or to 10 weekly sessions of a behavioral marital therapy (BMT) or an interactional couples group. The cost-benefit analysis of BMT plus individual alcoholism counseling showed (a) decreases in health care and legal costs in the 2 years after as compared to the year before treatment, (b) a positive cost offset, and (c) a benefit-to-cost ratio greater than 1 indicating that health and legal system cost savings (i.e., benefits) exceeded the cost of delivering the BMT treatment. None of the positive cost-benefit results observed for BMT were true for participants given interactional couples therapy plus individual alcoholism counseling for which posttreatment utilization costs increased. Thus, adding BMT to individual alcoholism counseling produced a positive cost benefit, whereas the addition of interactional couples therapy did not. Individual counseling both alone and with BMT added showed substantial and significant cost savings from reduced utilization that substantially and significantly exceeded the cost of delivering the treatment; and the two treatments did not differ significantly on these cost savings and cost offsets. Individual counseling alone did have a significantly more positive benefit-to-cost ratio than BMT plus individual counseling due to the lower cost of delivering the individual counseling which was about half the cost of delivering BMT plus individual counseling. Cost-effectiveness analyses indicated that BMT plus individual counseling was less cost effective than individual counseling alone and modestly more cost effective than interactional therapy in producing abstinence from drinking. When marital adjustment outcomes were considered, the three treatments were equally cost effective except during the active treatment phase when BMT was more cost effective than interactional couples therapy. Study limitations are discussed.

Assessing depression in alcoholics with the BDI, SCL-90R, and DIS criteria.

Depression was assessed in a sample of alcohol-dependent inpatients using the Beck Depression Inventory (BDI), Diagnostic Interview Schedule (DIS), and the SCL-90R. Initially, comparisons were made regarding the prevalence of depression among the three scales, and then regarding the relationship of each depression scale to symptoms of alcohol dependence and amount of drinking. Subjects were 59 inpatients enrolled in an alcohol-dependence treatment program at a university-affiliated health center. The prevalence of depression in the sample ranged from 20% with the DIS criteria to 42% with the SCL-90R. The relationship of depression to measures of alcohol dependence varied, depending upon the scale. Symptoms of alcohol dependence did not differ between depressed and nondepressed subjects using the DIS current or lifetime diagnosis, but symptoms of alcohol dependence were greater among those subjects considered depressed according to the other scales. Possible reasons for such differences are discussed, as are both clinical and research considerations.

Behavioral marital therapy with and without additional couples relapse prevention sessions for alcoholics and their wives.

This study evaluated whether alcoholics who received couples relapse prevention (RP) sessions in the year after short-term behavioral marital therapy (BMT) did better than those who did not receive additional RP. Couples (n = 59) with an alcoholic husband, after participating in weekly BMT couples sessions for 5 months, were assigned randomly to receive or not receive 15 additional conjoint couples relapse prevention (RP) sessions over the next 12 months. Outcome measures were collected before and after BMT and at quarterly intervals for the year after BMT. Significant improvements in the alcoholics' drinking and the couple's marital adjustment occurred from before to after BMT replicating results of our own and other's earlier studies of BMT with alcoholics, and outcomes remained significantly improved through 12-months follow-up independent of the amount of aftercare received. Given these favorable outcomes overall, the present study provided a stringent test of the hypothesized utility of RP. As predicted, alcoholics who received RP after BMT had more days abstinent and fewer days drinking, maintained their improved marriages better and used behaviors targeted by BMT more than those who received BMT alone. The prediction that greater continued use of behaviors targeted by BMT would be associated with better outcomes irrespective of the amount of aftercare received also was supported. The final prediction that couples with more severe alcohol and marital problems at study entry would show the greatest additional benefit from RP was not supported. The relatively clear-cut findings favoring RP may be due to the fact that RP in this study was an intensive, multifaceted booster maintenance intervention delivered in a couples format over a lengthy period of time. Moreover, the present results occurred during the time that couples were still getting RP. Limitations to the generalizability and interpretation of the results are discussed.

Sexual satisfaction and dissatisfaction in the marital relationships of male alcoholics seeking marital therapy.

Twenty-six married couples with alcoholic husbands who sought marital therapy were compared with two groups of couples without alcohol-related problems, 26 couples with marital conflict (MC) and 26 with no marital conflict (NC), on a range of sexual satisfaction variables. As predicted, the alcoholic and MC couples did not differ and both of these groups of couples reported less sexual satisfaction than the NC couples. Alcoholic and MC couples, in comparison with NC couples, reported less frequent intercourse, more change desired in intercourse frequency, greater misperception about the amount of change in sex frequency desired by their mate and more disagreement about sex. In addition, the finding that older alcoholics had less frequent intercourse replicated similar results by Jensen. Limitations of the present research and needed future research are discussed.

Effects of retesting with the Beck and Zung depression scales in alcoholics.

The present study assessed the presence of testing effects arising from the repeated administration of both the Beck and Zung depression scales to a group of 60 inpatient alcoholics. Thirty-seven men and 23 women were randomly assigned to one of three groups and administered the depression scales on one, two or three occasions, in successive weeks of treatment. Although the between group comparisons of initial test administration did not indicate a true change in depression, a within group comparison of initial with subsequent test administrations indicated a clear improvement in depression scores on both scales. Apparently the result of the reactive effects of testing, the within group differences could easily mislead a researcher into believing depression was alleviated when in fact it was not. This sizeable testing effect has obvious implications for studies which repeatedly assess depression.

Discriminative control of alcoholics' drinking by the drinking situation.

Implicit in what has come to be called the loss of control concept is the notion that the environment, or the context within which drinking occurs, exerts little influence on the quantity of alcohol consumed by an alcoholic. In contrast, recent formulations of the alcohol dependence syndrome have argued that dependence arises from an interaction among personality, pharmacological and contextual variables. The present study investigated the relationship between contextual factors and alcohol consumption in 231 men and 90 women alcoholics. Self-report questionnaire data were obtained describing social pressures to drink more or less than usual, and the usual quantity of drinking in a variety of situations (e.g., at home alone, in bars or in family settings). The findings indicate clear differences in the quantities that alcoholics drink when alone, with friends or with family. Even the dependent drinker is apparently able to discriminate the relative quantity of drinking that will be socially sanctioned in a given situation and modify consumption accordingly. In situations in which constraints are absent or minimal (e.g., alone), drinking tends to be greater than in situations in which social controls are more pronounced (e.g., with friends and family).