Family-involved alcoholism treatment. An update.

We reviewed 36 randomized studies of family-involved treatment and comparison conditions. A meta-analysis showed a medium effect size favoring family-involved treatments, over individual treatment or wait-list, for outcomes of alcohol use, treatment entry/attendance, and family adjustment. Studies of family-involved treatment when the alcoholic is unwilling to seek help show: (1) Al-Anon facilitation and referral help family members cope better; (2) the popular Johnson intervention apparently does not effectively promote treatment entry; and (3) Community Reinforcement and Family Training promotes treatment entry and should be disseminated if replicated. Studies of family-involved treatment to aid recovery when the alcoholic has sought help show: (1) evidence supporting behavioral couples therapy (BCT) has grown considerably; (2) the disulfiram contract procedure should be disseminated as part of a BCT treatment package; and (3) studies of family systems and of family disease approaches are beginning to appear in the literature. Future studies need to include more women and minority patients and focus on children.

Identification of structural elements important for matrix metalloproteinase type V collagenolytic activity as revealed by chimeric enzymes. Role of fibronectin-like domain and active site of gelatinase B.

Digestion of type V collagen by the gelatinases is an important step in tumor cell metastasis because this collagen maintains the integrity of the extracellular matrix that must be breached during this pathological process. However, the structural elements that provide the gelatinases with this unique proteolytic activity among matrix metalloproteinases had not been thoroughly defined. To identify these elements, we examined the substrate specificity of chimeric enzymes containing domains of gelatinase B and fibroblast collagenase. We have found that the addition of the fibronectin-like domain of gelatinase B to fibroblast collagenase is sufficient to endow the enzyme with the ability to cleave type V collagen. In addition, the substitution of the catalytic zinc-binding active site region of fibroblast collagenase with that of gelatinase B increased the catalytic efficiency of the enzyme 3- to 4-fold. This observation led to the identification of amino acid residues, Leu(397), Ala(406), Asp(410), and Pro(415), in this region of gelatinase B that are important for its efficient catalysis as determined by substituting these amino acids with the corresponding residues from fibroblast collagenase. Leu(397) and Ala(406) are important for the general proteolytic activity of the enzyme, whereas Asp(410) and Pro(415) specifically enhance its ability to cleave type V collagen and gelatin, respectively. These data provide fundamental information about the structural elements that distinguish the gelatinases from other matrix metalloproteinases in terms of substrate specificity and catalytic efficiency.

Behavioral couples therapy versus individual-based treatment for male substance-abusing patients. An evaluation of significant individual change and comparison of improvement rates.

Fals-Stewart, Birchler, and O'Farrell (1996) found that married or cohabiting substance-abusing men (n = 40) who participated in behavioral couples therapy (BCT) in addition to individual-based treatment (IBT) for substance abuse had fewer days of substance use and, along with their partners, reported higher levels of dyadic adjustment during and 1-year after treatment than husbands who received IBT only (n = 40). In the present study, significant individual change in posttreatment frequency of substance use and dyadic adjustment was evaluated and comparisons of the proportions of participants receiving IBT and BCT who were improved, unchanged, or deteriorated in these domains of functioning were made using data from Fals-Stewart et al. (1996). Growth curve analysis revealed that a larger proportion of husbands in the BCT condition showed significant reductions in substance use (n = 33, 83%) than husbands who received IBT (n = 24, 60%). Also, a larger proportion of couples who participated in BCT showed improvements in dyadic adjustment (n = 24, 60%) than couples whose husbands received IBT only (n = 14, 35%).

The timeline followback reports of psychoactive substance use by drug-abusing patients: psychometric properties.

The Timeline Followback (TLFB; L. C. Sobell & M. B. Sobell, 1996) interview, which uses a calendar method developed to evaluate daily patterns and frequency of drinking behavior over a specified time period, has well-established reliability and validity for assessing alcohol consumption. Although several investigators have used the TLFB to evaluate drug-using behavior, few studies have examined the psychometric properties of the interview for this purpose. The authors conducted TLFB interviews with a sample of adult drug-abusing patients seeking treatment for substance abuse (n = 113) at baseline, posttreatment, and quarterly thereafter for 12 months. It was found that the patients' reports about their drug consumption using this method generally had high (a) retest reliability, (b) convergent and discriminant validity with other measures, (c) agreement with collateral informants' reports of patients' substance use, and (d) agreement with results from patients' urine assays.

Behavioral couples therapy for alcoholism and drug abuse.

Behavioral couples therapy (BCT) sees the substance-abusing patient with the spouse to arrange a daily "sobriety contract" in which the patient states his or her intent not to drink or use drugs and the spouse expresses support for the patient's efforts to stay abstinent. BCT also teaches communication and increases positive activities. Research supports three conclusions. First, BCT for both alcoholism and drug abuse produces more abstinence and fewer substance-related problems, happier relationships, fewer couple separations and lower risk of divorce than does individual-based treatment. Second, domestic violence is substantially reduced after BCT for both alcoholism and drug abuse. Third, cost outcomes after BCT are very favorable for both alcoholism and drug abuse, and are superior to individual-based treatment for drug abuse. The Institute of Medicine (1998) documented a large gap between research and practice in substance abuse treatment. BCT is one example of this gap. BCT has relatively strong research support, but it has not yet become widely used.

Domestic violence before and after alcoholism treatment: a two-year longitudinal study.

OBJECTIVE: An initial study of 88 male alcoholics and their wives had shown that domestic violence decreased significantly in the year following a behavioral marital therapy (BMT) alcoholism treatment program (see J. Cons. Clin. Psychol. 63: 256-262, 1995). To determine if violence reductions were stable, the present study examined domestic violence during the second year following BMT for the 75 (of the original 88) couples who provided 2-year follow-up data on violence. METHOD: The prevalence and frequency of domestic violence were assessed for 75 male alcoholics and their wives at entry to and at 1 and 2 years after completing BMT. Data on frequency and consequences of alcoholics' drinking were collected for the 2-year follow-up period. Comparison rates of domestic violence for a demographically matched nonalcoholic sample were derived from a nationally representative survey of violence in American families. RESULTS: Husband-to-wife violence occurred in nearly two-thirds of cases in the year before BMT. For both the first and second year after BMT, violence was significantly reduced and the extent of violence was associated with the extent of the alcoholics' drinking. Frequency of posttreatment drinking was positively correlated with violence, and remitted alcoholics no longer had elevated domestic violence levels when compared with matched controls whereas relapsed alcoholics did. Analyses using various assumptions about violence for the 13 cases without violence data showed that sample attrition did not invalidate the present results. CONCLUSIONS: These results indicate that domestic violence decreased after BMT alcoholism treatment. Further, among remitted alcoholics, violence returned to the level experienced by other American families, in the same way that other aspects of marital, family and psychosocial functioning improve after successful treatment of alcoholism.

Alcoholism treatment and the family: do family and individual treatments for alcoholic adults have preventive effects for children?

OBJECTIVE: This article identifies findings on alcoholism treatment and the family that may have implications for prevention of mental health and substance abuse problems in children. METHOD: We conducted a brief overview of research on family treatment for alcoholism and on family adjustment after individual treatment for the alcoholic. RESULTS: Behavioral couples therapy with alcoholics and remission after individual alcoholism treatment have been associated with improved family functioning in a variety of domains, including reduced family stressors; improved marital adjustment; reduced domestic violence and verbal conflict; reduced risk of separation and divorce; improvement in important family processes related to cohesion, conflict and caring; and reduced emotional distress in spouses. These family factors have been linked with child mental health and psychosocial functioning in more general child developmental and psychopathology studies. CONCLUSIONS: Research is needed to find out whether behavioral couples therapy or individual treatment for an alcoholic parent has beneficial and preventive effects for children, reducing their risk for mental health and substance abuse problems. Studies should determine whether there is a specific link between (a) improvements in family stressors, violence and verbal aggression, marital adjustment and stability and (b) child, adolescent and young adult outcomes for the children in these families.

Drug-abusing patients and their intimate partners: dyadic adjustment, relationship stability, and substance use.

The dyadic adjustment and substance use of couples with a drug-abusing husband (n = 94), couples with a drug-abusing wife (n = 36), couples in which both partners abused drugs (n = 87), and non-substance-abusing conflicted couples (n = 70) were examined. For couples with 1 drug-abusing partner, a higher percentage of days abstinent during the year before treatment for drug abuse was associated with a higher level of relationship satisfaction. When both partners abused drugs, the relationship between percentage of days abstinent and relationship satisfaction became stronger and more negative as the time partners spent together using drugs increased. A higher percentage of days abstinent was associated with relationship stability for couples with 1 drug-abusing partner during and 1 year after treatment; for couples in which both partners abused drugs, a higher percentage of days abstinent was associated with relationship instability.

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.

Twelve-month abstinence from alcohol and long-term drinking and marital outcomes in men with severe alcohol problems.

OBJECTIVE: Clinical and research data suggest that drinking behavior during the first year following treatment for alcohol problems may predict longer term drinking and functioning in other areas. The purpose of this study was to investigate the relationship between abstinence from alcohol during the first year following group behavioral marital therapy (BMT) for alcohol problems and drinking and marital functioning through 30 months post-group BMT. METHOD: The subjects were 73 white male veterans with severe alcohol problems who participated in a clinical trial of group BMT and individual BMT aftercare. All subjects who entered the clinical trial were classified as either abstinent from alcohol for the full first 12 months following completion of group BMT, or not. Following completion of group BMT, subjects were reevaluated on drinking, marital functioning and related behaviors at 3, 6, 12, 18, 24 and 30 months later. RESULTS: Outcome analyses, taking into account baseline differences between drinker groups on age, marital functioning and number of days light drinking, showed better alcohol use (18, 24 and 30 months) and marital functioning (6, 12, 18, 24 and 30 months) for the first-year abstainers. Furthermore, fewer first-year abstainers than drinkers reported they were hospitalized for alcohol-related reasons at the 18-, 24- and 30-month follow-ups, and the abstainers showed a greater degree of self-efficacy not to drink heavily at each of the 6-, 18- and 30-month follow-ups. CONCLUSIONS: The data are consistent with the literature in showing the prognostic value of first-year post-alcohol treatment abstinence for drinking and functioning in other life areas in the longer term. The findings suggest that at least shorter term abstinence should be considered as an outcome goal for individuals who present to alcohol treatment settings.

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.

The fibronectin-like domain is required for the type V and XI collagenolytic activity of gelatinase B.

Gelatinase B (matrix metalloproteinase-9) is able to degrade several extracellular matrix proteins, including gelatin, elastin, and collagen types IV, V, XI, and XIV. This enzyme contains a "fibronectin-like" domain which is composed of three tandem copies of a fibronectin type 2 homology unit inserted into its catalytic domain. We have studied the involvement of this domain in the substrate specificity of gelatinase B by expressing a mutant of the enzyme, in Escherichia coli, in which this domain has been deleted. This mutant enzyme retained its ability to cleave the peptide substrate Mca-PLGL(Dpa)AR-NH2, possessing K(m) and kcat values similar to those of the wild-type enzyme. In addition, the NH2-terminal, 14-kDa, inhibitory domain of recombinant tissue inhibitor of metalloproteinase-2 was able to inhibit the mutant and the wild-type enzymes with the same potency. The mutant's gelatinolytic activity was also retained but reduced in comparison to that of the wild-type enzyme. However, contrary to the wild-type enzyme, the mutant was not able to digest or bind fibrillar collagen types V and XI. These data indicate that the fibronectin-like domain of gelatinase B is an important determinant of the enzyme's fibrillar collagen substrate specificity. It allows the enzyme to bind to and cleave collagen types V and XI, events which are thought to be involved in several normal physiological and pathological processes such as metastasis and arthritis.

Behavioral couples therapy for male substance-abusing patients: a cost outcomes analysis.

The cost outcomes for married or cohabiting substance-abusing male patients (N = 80) who were randomly assigned to receive either behavioral couples therapy (BCT) or individual-based treatment (IBT) were compared. Social costs incurred by patients in several areas (e.g., cost of substance abuse treatment, support from public assistance) during the year before and the year after treatment were estimated. BCT was more cost-beneficial than IBT; although the monetary outlays for delivering IBT and BCT were not different, the average reduction in aggregate social costs from baseline to follow-up was greater for patients who received BCT (i.e., $6,628) than for patients who received IBT (i.e., $1,904). BCT was also more cost-effective than IBT; for each $100 spent on the treatment, BCT produced greater improvements than IBT on several indicators of treatment outcome (e.g., fewer days of substance use, fewer legal problems).

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.

Couple communication patterns of maritally aggressive and nonaggressive male alcoholics.

OBJECTIVE: This study was conducted to examine the associations between communication problems and marital violence in couples with a male alcoholic, and to determine whether the communication correlates of marital violence found in nonalcoholic community samples also characterize male alcoholics' relationships. METHOD: Ninety newly abstinent treatment-seeking male alcoholics and their wives completed a 10-minute problem discussion while both partners were sober. Their communication behaviors were coded with the Marital Interaction Coding system. Couples were separated into maritally aggressive (n = 60 couples) and nonaggressive (n = 30 couples) groups on the basis of any husband-to-wife physical aggression in the previous 12 months. RESULTS: The base-rate percentage of aversive-defensive communication was significantly higher for couples with a physically aggressive husband than for couples with a nonaggressive husband. The base-rate percentage of facilitative-enhancing communication did not differ significantly between groups. In sequential analyses, physically aggressive husbands, but not their wives, displayed more negative reciprocity than their nonaggressive counterparts. Alcoholic husbands in general displayed lower rates of facilitative-enhancing communication than did their wives. CONCLUSIONS: Husband-to-wife marital aggression was associated with problematic communication among couples with an alcoholic husband during a sober interaction in a laboratory setting, extending prior nonalcoholic community sample research to male alcoholics' relationships. The maritally aggressive alcoholics were high in negative responses contingent upon their wives' prior negative behavior, and were unlikely to terminate aversive interchanges. Communication problems may be important in understanding and treating co-occurring alcoholism and marital violence.

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.

Behavioral couples therapy for male substance-abusing patients: effects on relationship adjustment and drug-using behavior.

Married or cohabitating substance-abusing patients (N = 80) who were entering individual outpatient treatment, most of whom were referred by the criminal justice system (n = 68; 85%), were randomly assigned to a no-couples-treatment control group (n = 40) or to 12 weekly sessions of adjunctive behavioral couples therapy (BCT; n = 40). Drug use and relationship adjustment measures were collected at pretreatment, posttreatment, and at 3-, 6-, 9-, and 12-month follow-ups. Couples who received BCT as part of individual-based treatment had better relationship outcomes, in terms of more positive dyadic adjustment and less time separated, than couples in which husbands received individual-based treatment only. Husbands in the BCT condition also reported fewer days of drug use, longer periods of abstinence, fewer drug-related arrests, and fewer drug-related hospitalizations through the 12-month follow-up period than husbands receiving individual-based treatment only. However, some of the drug use and relationship adjustment differences between these groups dissipated over the course of the follow-up period.

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.

Relapse precipitants and behavioral marital therapy.

The major purpose of this study was to provide descriptive data on the first relapse episodes and reasons for terminating relapses of subjects who completed a course of behavioral marital therapy (BMT) for alcoholism. Another aim of the study was to compare the relapse episodes and relapse terminations of subjects who received BMT with or without additional relapse prevention (RP) treatment for one year. The subjects were selected from a sample of 74 men who began an outpatient Department of Veterans Affairs BMT program. These men were evaluated pre- and post-BMT, and at 3, 6, 9, and 12 months after completing BMT. A total of 31 subjects relapsed at least once after they began BMT. The data showed that these men tended to report more than one situational or personal precipitant of their first relapses. Similarly, they tended to report more than one reason for ending their relapse episodes. Comparison of the subjects assigned to the two RP conditions revealed an equal number (12) of relapse episodes, but RP subjects' relapses tended to last fewer days than did no-RP subjects'. The consistency of these findings with previous research on cognitive-behavioral models of relapse and the implications of these findings for the concept of high-risk situation, are discussed.