Expressed emotion and relapse in alcoholic patients.

Although family members' expressed emotion (EE) predicts patients' elevated relapse rates in schizophrenia and mood disorders, little is known about the relationship between EE and relapse in alcoholism. For 86 alcoholic patients (78 men, 8 women), the association between the spouse's EE and the alcoholic patient's subsequent relapse status in the 12 months after the couple began an outpatient behavioral marital therapy (BMT) program for alcoholism was examined. Alcoholic patients with high EE spouses, when compared with their counterparts with low EE spouses, were more likely to relapse, had a shorter time to relapse, and drank on a greater percentage of days in the 12 months after starting BMT. EE continued to be associated with relapse after patients' age, education, and alcohol problem severity were taken into account. Greater use of Antabuse and more sessions of BMT were associated with reduced relapse for alcoholic patients with high EE spouses.

Sexual adjustment of male alcoholics: changes from before to after receiving alcoholism counseling with and without marital therapy.

Married male alcoholics (N = 36), who had recently begun individual outpatient alcoholism counseling, were randomly assigned to a no-marital-treatment control group or to 10 weekly sessions of either a behavioral marital therapy (BMT) or an interactional couples therapy group. Impotence decreased from before to after counseling irrespective of whether the alcoholic patients received additional marital therapy. Husbands who received BMT reported increased frequency of wives' orgasm during intercourse and greater increases in satisfaction with the privacy and context of their sexual activities than did couples in the other two treatment groups. These findings support a biopsychosocial formulation of alcoholics' sexual problems that implicates the physical effects of acute and chronic alcohol intake as most relevant to the elevated rates of impotence and marital conflict as a major contributing factor to most sexual problems of alcoholics. The improvement observed in sexual adjustment was rather limited. Despite the improvements in impotence, the alcoholics still experienced over twice the rate of impotence reported by demographically similar nonalcoholics. In terms of sexual satisfaction, BMT produced only modest gains as viewed by husbands and no gains from the wives' perspective. Perhaps sexual adjustment is one of the last areas of the alcoholic's marriage to improve after treatment. The limited time frame of the present study may have precluded observing further improvements in sexual adjustment that would emerge later after a longer period of recovery.

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.

Alcoholics Anonymous affiliation during early recovery.

This study analyzed the Alcoholics Anonymous (AA) participation of 55 patients during the 3 months after their discharge from structured treatment, when dropout is high. Three levels of meeting attendance were discerned: low, mid-level, and "90 meetings in 90 days." Of greatest interest, the mid-level group showed mixed interest in AA practices despite substantial meeting attendance, that is, they admitted powerlessness, but had less enthusiasm for the higher power concept, and relapsed significantly; they were likely to have a sponsor, but were less involved with other AA members; and they reported working the 12 Steps, but were less interested in the AA literature. Findings suggest that individuals who are attending AA but having difficulty embracing key aspects of the program need professional assistance that focuses more on AA practices and tenets and less on meeting attendance. Barriers to affiliation can also serve as opportunities for furthering both counseling goals and affiliation.

A Sexual Adjustment Questionnaire for use in therapy and research with alcoholics and their spouses.

Despite evidence of extensive sexual problems among alcoholics, sexual adjustment is an area of alcoholics' behavior that often has been neglected in both treatment and research. To facilitate work on alcoholics' sexual adjustment, we needed a self-report questionnaire on sexual behavior that we could use in our couples treatment program with alcoholics and in our longitudinal research on the course of alcoholics' sexual problems over time. Pilot work found that available sexual adjustment measures were either too long or too sexually explicit to be useful. This paper describes the 38-item Sexual Adjustment Questionnaire we developed by combining selected items from two existing measures. Factor analysis reduced the questionnaire to the 15 measures of sexual satisfaction and sexual dysfunction described herein. Preliminary normative data and evidence of construct validity, potential clinical and research uses of the questionnaire, and suggestions for future studies are described.

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.

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.

Sensation seeking and novelty seeking. Are they the same?

Responses to Zuckerman's Sensation Seeking Scale (SSS) and Cloninger's Tridimensional Personality Questionnaire (which consists of novelty seeking, harm avoidance, and reward-dependence dimensions) have been linked to a variety of behavioral and psychiatric variables. The relationship of these two measures to one another has not been examined previously and, in the present study, is evaluated in a group of men briefly hospitalized for treatment of alcohol and chemical dependence. Total sensation seeking scale scores were significantly correlated (Pearson r) with total novelty seeking scale scores. Set correlation analysis revealed significant overall relationships between sensation seeking and both high novelty seeking and low harm avoidance. Most of these overall relationships were attributable to six subscales, although broad relationships were observed between the SSS disinhibition and novelty seeking subscales, and between a harm avoidance subscale and all SSS subscales. Neither statistical approach identified an association between reward dependence and sensation seeking.

Family history models of alcoholism: age of onset, consequences and dependence.

The association of a family history of alcoholism to susceptibility to alcoholism has been well documented over the past 3 decades. The classification of a family history of alcoholism commonly involves the division of subjects into family history positive and negative groupings. However, diverse definitions are used to define positive family histories. These diverse definitions of family alcoholism impede the comparison of results from different studies. The present study evaluates several classification schemes and compares them with a new method for the analysis of family patterns of alcoholism (FPA). A sample of 220 male alcoholic veteran inpatients were assessed for age of onset of alcoholism, consequences of drinking and the severity of their dependence. Multiple regression equations were estimated for several dichotomous family history models and each model was evaluated against a comparable FPA model that included the same family members. Comparisons of the classification models with the equivalent FPA analysis model facilitated comparisons of the contribution of each family history designation to changes in amount of explained variance. In all instances, the FPA analyses explained more variance than did the comparable dichotomous family history models. In addition, the FPA analyses reveal the relative explanatory power of each family member and indicate that maternal relatives often have a more important contribution than has been indicated previously.

Abstinence, reasons for not drinking, and life satisfaction.

This study examines the reasons given for not drinking by abstinent alcoholics with varying lengths of sobriety. A Reasons for Not Drinking Scale is tested, as well as the Purpose in Life Questionnaire and Life Satisfaction Scale. Subjects are 60 males from a VA population. Results show that subjects with less education and those treated in a detoxification setting are more likely to endorse negative reasons for not drinking. Individuals with short and long abstinence have a higher level of life "dissatisfaction" than those with moderate periods of abstinence. The study suggests that purpose in life, life satisfaction, and reasons for not drinking are important measures of progress in treatment and movement through phases of recovery.

Services for families of alcoholics: a national survey of Veterans Affairs treatment programs.

Directors of 70 (75% response rate) inpatient and 51 (54% response rate) outpatient alcoholism treatment programs run by the Department of Veterans Affairs (VA) returned questionnaires about patient and program characteristics and the extent of use of family-focused treatment modalities. Referrals to Al-Anon for spouses and to Alateen for teenage children were by far the most frequently provided services. Conjoint couples therapy was the type of direct service provided most frequently. Couples group therapy for outpatient programs and spouse education groups for inpatient programs were the next most frequently used. Family therapy was not used frequently. The majority of programs did not offer services directed at the individual needs of spouses, such as individual or group therapy and educational groups. Finally, services to children of alcoholics were nearly nonexistent being limited to referral of teenage children to Alateen. Marital and family services other than referral to Al-Anon and Alateen and conjoint couple interviews in inpatient programs were provided to fewer patients than those eligible for the services. The extent of family services offered bore little or no relationship to program characteristics (e.g., funding level, staffing pattern) but was related to patient characteristics. Programs with more middle-aged, employed, high school (or better) educated, married veterans made greater use of family-focused modalities. The results suggest the VA needs to develop policy guidelines for the type and intensity of marital and family services their programs should provide with specific determination of what responsibility, if any, VA programs have to the children living with the alcoholic veterans treated in these programs.

Drinking experiences in three populations of male drinkers.

The first drinking experience has been suggested as an important point in etiological processes associated with alcohol use and abuse. In this study, initial drinking experiences were assessed among populations of alcoholics, problem drinkers, and non-problem drinkers. Results showed that the alcoholics and problem drinkers more frequently consumed 5 or more drinks during their initial drinking occasion than the nonproblem drinkers. Alcoholics were most likely to experience their second drinking event within several days. In addition, there was a tendency for alcoholics and problem drinkers to describe more negative effects associated with their initial drinking experience. No effects were found for age of first drink or its location. Such differences in first drinking may have implications for understanding the etiology of drinking problems.

Alcohol use by alcoholics with and without a history of parental alcoholism.

The association between parental history of alcoholism and the nature of alcoholism was assessed using a more reliable measure of family history (Family Tree Questionnaire) and a more comprehensive inventory of alcoholism (Alcohol Use Inventory) than used in earlier studies. Parental alcoholism was associated with more severe alcoholism on most parameters of alcohol use (age of onset, quantity, frequency, preoccupation, and sustained use) and alcohol-related problems (social, vocational, physical, cognitive, and loss of control). The association between parental history of alcoholism and more severe alcoholism in the probands was independent of age of onset of alcoholism, current age, socioeconomic background, and marital status. Parental history positive (PH+) alcoholics were more reliant on alcohol to manage their moods but did not differ significantly from parental history negative (PH-) alcoholics in the use of alcohol to improve sociability or mental functioning or to cope with marital problems. Surprisingly, the degree of concern, guilt, and worry over the negative consequences of drinking was not significantly different for PH+ alcoholics although the negative consequences were clearly much more severe for this group. While the data are inconclusive about the reasons for more severe alcoholism in PH+ alcoholics, greater reliance on ethanol to manage moods and a relative insensitivity to negative consequences could theoretically account for the vulnerability to more severe alcoholism found in PH+ alcoholics.

Using a drinking motivation scale to predict degrees of problematic drinking.

Much of the recent interest in the role of cognitive factors in decisions to drink has focused on alcohol beliefs and drinking motivations. In this study, male alcoholics in treatment, untreated problem drinkers and non-problem drinkers were studied using a variation of the Mulford and Miller Definitions of Alcohol Scale, which assesses personal-deficiency and social/celebratory reasons for drinking. The three groups of drinkers differed significantly on their mean level of endorsement of items comprising each drinking motivation subscale. The alcoholics scored highest on both personal-deficiency and social/celebratory reasons for drinking, followed by the problem drinkers and then non-problem drinkers. The problem drinkers and non-problem drinkers, relative to the alcoholics, rated their social/celebratory reasons for drinking stronger than their personal-deficiency reasons. A multiple discriminant analysis yielded a function which was moderately successful in classifying the alcoholics (70% correctly classified) and non-problem drinkers (67%). The problem drinkers were much more difficult to correctly classify (32% were classified as alcoholic, 49% as non-problem drinkers). The findings suggest that potentially important differences exist in drinkers' motivations to consume alcohol, motivations that vary as a function of problem drinking severity. These are results which might productively be used in assessment and treatment endeavors.

Dose-related effects of alcohol among male alcoholics, problem drinkers and nonproblem drinkers.

Cognitive variables, such as expectancies regarding the usefulness of alcohol, have been receiving increased attention in recent years because these expected effects can influence decisions to drink and mediate responses to alcohol. In the present study, alcohol expectancies were assessed using the Alcohol Beliefs Scale, a measure that yields dose-related data on expected effects of alcohol. The subjects were male alcoholics, problem drinkers and nonproblem drinkers. The central finding was that drinker group membership and rated dose level interacted in predicting subjects' estimates of the usefulness of alcohol for them. On the "useful for feeling better" factor, the greatest benefit was expected from a moderate dose, particularly among alcoholics. On the "useful for relieving emotional distress" factor, usefulness ratings increased with dose, with alcoholics expecting the greatest rate of increase. A similar pattern was found for the "useful for feeling in charge" factor, except that the ratings for problem drinkers and alcoholics paralleled each other. These findings have implications for our efforts to understand drinkers' motivations to initiate and continue drinking.

Experience with alcohol and the endogenous opioid system in ethanol analgesia.

This study employed naloxone, an opiate antagonist, to explore whether a learned opioid response, mediated by drinking experience, accounts for ethanol and placebo analgesia. Cold pressor pain was evaluated before and after ethanol (0.5 g/kg), placebo, and no-alcohol control treatments (administered in randomized order) and again after double-blind administration (6 mg/kg) of naloxone to 11 men and saline to 9. A triple interaction of treatments, antagonist conditions, and drinking experience indicated that naloxone as compared to saline diminished ethanol and placebo analgesia among experienced drinkers but had opposite effects among the same men in the control treatment. Six men, who reported that the injection of naloxone had an effect on pain, had higher drinking experience scores than the five men who reported naloxone had no effect. The similar pattern of response to both the alcohol and the placebo treatments suggests that the opioid system response to alcohol is learned.

Experience and change in Al-Anon family groups: adult children of alcoholics.

Adult children of alcoholics exhibit low self-esteem, excessive feelings of responsibility, difficulties reaching out, depression and the increased likelihood of alcoholism. This study examines how adult children of alcoholics discuss their experiences in an Al-Anon group and describes their perceptions of change in self, personal problems, relationships, spirituality, childhood and the Al-Anon program. Twelve sessions of one Al-Anon chapter were observed, Al-Anon members were interviewed and a coding system to assess the content of the meetings was developed. Improvements constituted 25% of reports, of which improvement in problems constituted 20%. Members reported positive changes in self. Changes in relationships with alcoholics were few, as were changes in perceptions of the program (members felt positively about the program from the start). Although spirituality constituted less than 4% of the reports, many interviewees found spirituality the last and, ultimately, one of the most valued components of Al-Anon. A common experience of parental alcoholism, and cognitive, affective and behavioral antidotes to prior socialization in an alcoholic family contributed to the program's perceived helpfulness.

Alcohol expectancies among male alcoholics, problem drinkers, and nonproblem drinkers.

Drinkers' expectancies regarding alcohol effects are cognitive factors hypothesized to affect decisions to drink and responses to alcohol. Recent research in this area has yielded descriptive data mostly on nonalcoholic drinkers' motives for drinking and alcohol expectancies. Much less attention has been focused on assessing the extent to which these findings generalize to a broader array of drinkers. Alcohol expectancies were assessed in this report among 260 alcoholics, 79 problem drinkers, and 81 nonproblem drinkers (all subjects were male) using a comprehensive alcohol expectancy measure. Alcoholics almost uniformly scored higher than the problem and nonproblem drinkers in their endorsements of alcohol's effects in different domains (e.g., alcohol acts as a global positive transforming agent, enhances physical and social pleasure, engenders assertiveness, reduces tension). Problem drinkers also tended to score higher than the nonproblem drinkers in these domains. A multiple discriminant analysis yielded two functions which together were moderately successful in classifying these subjects according to drinker group. Taken together, these data suggest that important individual differences exist in drinkers' expectations regarding alcohol's utility, and that alcohol expectancies vary considerably as a function of problem drinking severity. The clinical implications of these findings are discussed.