The problem-oriented record. Problem definition.

A problem is defined when the clinician judges a dysfunction is apparent or highly probable for the patient in one or more of three areas: physiological, psychological, or social functioning. In defining specific problems, data assessments are often confounded with the data themselves. To "lump" or "split" problems in psychiatry should be by theoretical and practical considerations. Problem indicators should be "split" when the clinician believes they are not different indicators of the same problem or treatments for the problem indicators will be different. They can be "lumped" when the clinician believes they are different indicators of the same problem, or when the treatment will be the same. Criteria supporting the belief of a single problem construct are met when indicators co-vary, are functionally equivalent, or respond similarly to the same treatment variable.

DSM-III and clinically identified problems as a guide to treatment.

Problems, DSM-III diagnoses, and treatment interventions were coded from the problem-oriented medical records of an acute psychiatric hospital. Problems and diagnoses were entered into separate stepwise multiple regression analyses to test their ability to predict 24 treatment interventions. Significant predictors were then included in a combined analysis. Both DSM-III diagnoses and problems were robust and significant indicators of medication treatments. Both were better predictors of medication than were problems and DSM-II diagnoses in an earlier study. With regard to psychosocial interventions, problems were better indicators than were DSM-III diagnoses, although neither was robust. Both were less useful as predictors of psychosocial interventions than in the earlier study. Overall, the combination of problems and diagnoses was generally superior in predictive power to either alone. These results suggest that problem nomenclature should include DSM-III diagnoses. Alternatively, DSM-III should be revised to accommodate some of the greater specificity and range of a problem nomenclature.

Validation of a problem-focused nomenclature.

To test the value of a problem-focused nomenclature, problems were compared with DSM-II diagnoses as predictors of treatment and outcome. Patient problems, diagnoses, and treatment plans were coded from the medical records of 779 psychiatric inpatients. Problems were found to predict treatment plans better than did diagnoses. The combination of problems and diagnoses, however, was the best predictor of treatment with psychotropic medications. Problems of over 300 patients were compared with diagnoses as predictors of patient outcomes in overall functioning, subjective well-being, family functioning and mental status. At two months, problems and diagnoses predicted outcome equally well while the two in combination afforded the best prediction. At one year, however, the variance in outcomes explained by diagnosis was one third less than that explained by problems.

The paradoxical underutilization of partial hospitalization.

Partial hospitalization continues to be underutilized even though its clinical effectiveness for a variety of psychiatric patients has been demonstrated. The authors investigated the potential economic advantage of partial hospitalization by comparing matched groups of day hospital patients and inpatients who had comparable symptoms and prognoses on admission. They present one-year follow-up data documenting the comparability of the study groups on clinical outcome measures and the cost advantages favorable the partial hospitalization group. They discuss possible causes of the paradoxical underutilization of the clinically effective and lower-cost partial hospitalization, which include institutional factors, patients' clinical characteristics, family resistance, and clinician bias.

Cognitive-behavioral treatment for alcohol dependence: a review of evidence for its hypothesized mechanisms of action.

OBJECTIVE: This review examined support for the hypothesis that cognitive-behavioral treatment (CBT) for alcohol dependence works through increasing cognitive and behavioral coping skills. METHOD: Ten studies were identified that examined the hypothesized mechanisms of action of CBT. These studies involved random assignment (or its near equivalent) of participants to CBT and at least one comparison condition. RESULTS: Although numerous analyses of the possible causal links have been conducted to evaluate whether CBT works through increasing coping, the results indicate little support for the hypothesized mechanisms of action of CBT. CONCLUSIONS: Research has not yet established why CBT is an effective treatment for alcohol dependence. Negative findings may reflect methodological flaws of prior studies. Alternatively, findings may indicate one or more conceptual assumptions underlying CBT require revision.

Interpersonal factors and post-treatment drinking and subjective wellbeing.

AIMS: A conceptual clarification of the domain of social relationships defines three aspects of social relationships (structure, function and quality), which have both alcohol-specific and general components. We analyse the correlations among post-treatment indicators of social relationships and the association between these interpersonal variables and post-treatment drinking and subjective wellbeing. DESIGN: This is a secondary analysis of data from an alcohol treatment outcome study, in which subjects were randomly assigned to one of three treatment conditions and followed for 18 months. SETTING: The outpatient treatment program is located within a private psychiatric hospital in the north-eastern United States. PARTICIPANTS: We analyzed the 140 subjects who completed a social network instrument 12 months following treatment assignment. INTERVENTION: This secondary analysis combined clients from three treatment conditions, all of which were based upon social learning theory. MEASUREMENTS: Interview and questionnaire self-report data were collected by trained interviewers. FINDINGS: Indicators of social relationships are found to be relatively independent of one another. Only alcohol-specific social relationship indicators are significantly associated with drinking outcomes, and only general indicators are significantly associated with subjective wellbeing. Functional indicators, addressing social interaction content, have stronger effects on outcomes than structural or quality indicators. General and alcohol-specific support from friends have more influence than support from family; both surpass the influence of co-workers. CONCLUSIONS: A better understanding of the roles of social relationships during the course of treatment and recovery or relapse may help clarify how treatment personnel can utilize clients' interpersonal relationships more effectively to maximize treatment effectiveness.

Age group differences in response to treatment for problematic alcohol use.

That structural characteristics act as markers of modified treatment outcome is a long standing idea in the alcohol treatment field. In order to test whether patient age is a factor to be considered in making treatment assignments, we examined data collected under a clinical trial. Two hundred and twenty-nine patients were randomly assigned to one of three treatment conditions: extended cognitive behavioral treatment (CB), relationship enhancement (RE), or relationship and vocational enhancement (VE). This paper reports on outcome (alcohol use) 3-6 months after treatment assignment. Our question was, would different age groups assigned to the treatment conditions exhibit different outcomes? There were no significant main effects by either treatment condition or age group. There was a significant treatment condition by age group interaction. With increasing age, the differences in treatment seemed to increase. For the younger aged group (18-29 years old) no statistically significant treatment differences were detected. Middle aged patients (30-49 years old) did best in the RE condition. Older aged patients (50 + years old) did best when assigned to the CB condition. These findings lead us to conclude that patient age is a variable which should be considered when testing patient-treatment matching hypotheses.

Predictive validity of Marlatt's relapse taxonomy versus a more general relapse code.

Marlatt's system for classifying relapses involves integrating information about the context of a relapse into a judgment about the most critical aspects of the situation. Constraints in this taxonomy, however, may limit its validity. On a sample of 300 subjects drawn from six treatment facilities, we compared the predictive validity of Marlatt's taxonomy with that of a coding scheme with fewer constraints. Marlatt's taxonomy does not significantly predict drinking outcome, nor does it predict time to relapse. There is weak evidence, however, that under some circumstances Marlatt's taxonomy can predict the type of relapse subsequently observed. The alternative coding system also does not seem useful for predicting drinking outcome, although a possible association was found between internal attribution and time to return to heavy drinking. The alternative system does seem to be able to detect repetitive aspects of subsequent relapse situations; lack of social interactions, family setting, anxiety and depression were most likely to repeat. It may be useful to consider these relapse attributes in treatment planning. The minimal predictive validity for both the Marlatt and the alternative relapse code may be due to weaknesses in the relatively unstructured interview used to gather the data, or to failure to assess the most critical dimensions relating to subsequent relapse.

Gender differences in relapse situations.

Gender differences in variables relating to alcohol treatment are receiving increased attention. Most reports indicate gender differences in both intrapersonal, interpersonal and environmental trans-situational variables that relate specifically to women's drinking. This study investigates gender differences in the immediate relapse situation itself. These differences are then examined in the context of trans-situational (i.e. across time) affective and cognitive variables and social support. This report is part of a larger study designed to replicate Marlatt's taxonomy of high risk situations for relapse, and to examine alternative methods of describing relapse situations. Three hundred subjects (169 men, 131 women) were recruited from six different inpatient and outpatient programs. Subjects were asked to identify their last relapse before entering the index treatment. Details of the drinking episode itself were also obtained, e.g. number of drinking days in episode, drinking to intoxication, presence of others. Measures of state and trait affect, expectancies, and social support were also collected. There were no gender differences in Marlatt's taxonomy, or in drinking topography during relapse. At baseline, women reported drinking less, and drinking less often than men. However, women drank to intoxication more often than men. Surprisingly, men relapsed alone more often than did women. Men and women report relapsing frequently with same sex friends, and women showed a tendency to relapse in the presence of romantic partners. Men also tend to report more positive mood states during relapse than women, which is congruent with the finding that women report more depression. Severity of drinking pattern was found to be an important confounding variable in these analyses. It is suggested that gender differences found in individuals in treatment for alcohol problems may reflect societal differences between men and women, and that taking these differences into account in designing treatment programs may improve outcomes.

Looking forward and back to relapse: implications for research and practice.

In this commentary, the three principal investigators of the Relapse Replication and Extension Project (RREP) reflect on clinical and research implications of study findings from the three collaborating sites. A primary purpose of RREP was to study the reliability and validity of a taxonomy of relapse antecedents originally proposed by Marlatt two decades ago. Under the best of research conditions, with extensive training and practice, it was difficult to achieve reliability of coding with the original three-level system, although with only two levels of classification more reasonable albeit variable reliability was found. Modifications may improve the taxonomy's reliability, but RREP data indicate that a more appropriate strategy is to measure possible antecedents of relapse by continuous scales such as those provided by Annis, Heather and Litman. There is reasonably consistent evidence for two common antecedents of relapse: negative emotional states, and positive emotional states in a social context. Antecedents of relapse show only modest consistency within individuals from one occasion to the next. The causes to which clients attribute relapses may exert a significant effect on future drinking episodes. Stable and internal attributions, such as are commonly associated with a dispositional disease model, may serve to perpetuate relapse. From the RREP studies, the availability of coping skills appears to be a potent protective factor, and ineffective coping a consistent predictor of relapse. Implications for clinical research and practice are considered.

Network support for drinking, Alcoholics Anonymous and long-term matching effects.

AIMS: (1) To examine the matching hypothesis that Twelve Step Facilitation Therapy (TSF) is more effective than Motivational Enhancement Therapy (MET) for alcohol-dependent clients with networks highly supportive of drinking 3 years following treatment; (2) to test a causal chain providing the rationale for this effect. DESIGN: Outpatients were re-interviewed 3 years following treatment. ANCOVAs tested the matching hypothesis. SETTING: Outpatients from five clinical research units distributed across the United States. PARTICIPANTS: Eight hundred and six alcohol-dependent clients. INTERVENTION: Clients were randomly assigned to one of three 12-week, manually-guided, individual treatments: TSF, MET or Cognitive Behavioral Coping Skills Therapy (CBT). MEASUREMENTS: Network support for drinking prior to treatment, Alcoholics Anonymous (AA) involvement during and following treatment, percentage of days abstinent and drinks per drinking day during months 37-39. FINDINGS: (1) The a priori matching hypothesis that TSF is more effective than MET for clients with networks supportive of drinking was supported at the 3 year follow-up; (2) AA involvement was a partial mediator of this effect; clients with networks supportive of drinking assigned to TSF were more likely to be involved in AA; AA involvement was associated with better 3-year drinking outcomes for such clients. CONCLUSIONS: (1) In the long-term TSF may be the treatment of choice for alcohol-dependent clients with networks supportive of drinking; (2) involvement in AA should be given special consideration for clients with networks supportive of drinking, irrespective of the therapy they will receive.

An outcome evaluation of a hospital-based early intervention program.

AIM: To determine the effectiveness of the Health Care Intervention Service (HIS), an early intervention program for general hospital patients with alcohol dependence or at risk for alcohol dependence. DESIGN, SETTING AND PARTICIPANTS: HIS consists of screening, assessment and assignment to either full or risk-reduction intervention. Full intervention includes a referral to treatment. Outcomes were compared across three groups: those who received a full intervention, those who received a risk-reduction intervention, and a comparison group of similar patients from hospitals with no HIS program. Patients were screened for alcohol involvement and interviewed during their hospitalization (prior to the intervention in HIS hospitals) and again 6 months following the intervention. FINDINGS: Full intervention was effective in increasing the probability of abstinence, reducing the number of heavy drinking days, and encouraging patients to accept the referral to treatment. Risk-reduction intervention was effective in reducing alcohol consumption and consequences, but only for those patients who had some signs of dependence at the first interview. CONCLUSIONS: HIS has demonstrated its effectiveness in a "real world" bureaucratic and clinical environment.

Alcoholism treatment and medical care costs from Project MATCH.

AIMS: This paper examines the costs of medical care prior to and following initiation of alcoholism treatment as part of a study of patient matching to treatment modality. DESIGN: Longitudinal study with pre- and post-treatment initiation. MEASUREMENTS: The total medical care costs for inpatient and outpatient treatment for patients participating over a span of 3 years post-treatment. SETTING: Three treatment sites at two of the nine Project MATCH locations (Milwaukee, WI and Providence, RI). PARTICIPANTS: Two hundred and seventy-nine patients. INTERVENTION: Patients were randomly assigned to one of three treatment modalities: a 12-session cognitive behavioral therapy (CBT), a four-session motivational enhancement therapy (MET) or a 12-session Twelve-Step facilitation (TSF) treatment over 12 weeks. FINDINGS: Total medical care costs declined from pre- to post-treatment overall and for each modality. Matching effects independent of clinical prognosis showed that MET has potential for medical-care cost-savings. However, patients with poor prognostic characteristics (alcohol dependence, psychiatric severity and/or social network support for drinking) have better cost-savings potential with CBT and/or TSF. CONCLUSIONS: Matching variables have significant importance in increasing the potential for medical-care cost-reductions following alcoholism treatment.

The Significant-other Behavior Questionnaire (SBQ): an instrument for measuring the behavior of significant others towards a person's drinking and abstinence.

The psychometric properties of the Significant-other Behavior Questionnaire (SBQ), an instrument measuring the specific social support in terms of the patient's drinking. Assessments of the significant other's behavior in the presence of the patient drinking is provided by both the patient and significant other. Data from the two SBQ forms were analyzed with a principal axis factor analytic procedure with varimax rotation. The scales were similar for the two forms with four behavioral reactions, withdraw from the patient, support drinking, support sobriety, and punish drinking. Correlations between the two forms on the same four scales were higher than correlations within groups on three of four scales and differed from measures of general social support. Applications of the SBQ are discussed.

The reliability of Marlatt's taxonomy for classifying relapses.

Marlatt's focus on the relapse situation has had a major impact upon research and clinical practice in treating addictions. One component of his work was the development of a taxonomy for classifying precipitants of relapse. This taxonomy has been incorporated into the nomenclature of clinicians and clinical researchers as part of an explanatory framework for understanding relapses. Despite the taxonomy's influence it has never been examined for the reliability of its use across research studies. The present study compared the reliability of independent classifications of 149 relapse episodes by trained raters at three research laboratories. Despite considerable across-laboratory training, reliability was found to be inconsistent for research purposes. It is concluded that comparability of results based on Marlatt's relapse taxonomy across independent studies must be subject to question, and assumptions necessary for the aggregation of a knowledge base are not supported. Recommendations are offered for improving the reliability of the taxonomy and the methods used to collect taxonomy data. More generally, questions regarding the value of the specific relapse categories, as well as the overall taxonomy, are raised.

Determinants of research follow-up participation in an alcohol treatment outcome trial.

This study examined factors associated with research attrition in a long-term follow-up study (48 months). Researchers attempted to contact all randomized participants, not just those who completed treatment. The processes by which baseline characteristics, early treatment-research experiences, and short-term outcome affected subsequent participations were examined using logistic regression. The analyses deal primarily with refusal, the main reason for attrition. Baseline characteristics had small effects on likelihood of refusal; research engagement had some impact; but treatment participation had strong effect. Short-term outcome did not predict refusal. These findings, if generalizable, have implications for the conduct and reporting of outcome studies. By directly studying bias, rather than presuming its absence on skimpy evidence, researchers can achieve a better understanding of the strengths and limitations of outcome results.

Matching treatment focus to patient social investment and support: 18-month follow-up results.

Patients were randomly assigned to 1 of 3 treatments: brief broad-spectrum (BBS), extended relationship enhancement (ERE), or extended cognitive-behavioral (ECB). A hierarchical latent growth model was used to analyze the data of 188 patients (82%) followed for 18 months. ERE treatment was significantly more effective in increasing abstinence of patients entering treatment with a network unsupportive of abstinence or with a low level of investment in their network, whereas BBS treatment was more effective for patients with either (a) both a social network unsupportive of abstinence and a low level of network investment or (b) high investment in a network supportive of abstinence. ECB outcomes were neither as good as those matched nor as bad as those mismatched to the different exposures of relationship enhancement. This suggests that dose of relationship enhancement should be determined after assessing patient relationships.

The therapeutic alliance and its relationship to alcoholism treatment participation and outcome.

The relationship between the therapeutic alliance and treatment participation and drinking outcomes during and after treatment was evaluated among alcoholic outpatient and aftercare clients. In the outpatient sample, ratings of the working alliance, whether provided by the client or therapist, were significant predictors of treatment participation and drinking behavior during the treatment and 12-month posttreatment periods, after a variety of other sources of variance were controlled. Ratings of the alliance by the aftercare clients did not predict treatment participation or drinking outcomes. Therapists ratings of the alliance in the aftercare sample predicted only percentage of days abstinent during treatment and follow-up. The results document the independent contribution of the therapeutic alliance to treatment participation and outcomes among alcoholic outpatients.

Internal validity of Project MATCH treatments: discriminability and integrity.

Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) is a multisite collaborative project designed to evaluate patient-treatment interactions in alcoholism treatment. To evaluate whether major threats to the internal validity of the independent (treatment) variable in Project MATCH could be ruled out, we investigated several aspects of treatment integrity and discriminability. In this study, 1,726 alcohol-dependent participants at 10 sites were randomized to 3 treatments: cognitive-behavioral treatment (CBT), motivational enhancement therapy (MET), and 12-step facilitation (TSF). Participants received treatment either as outpatients or as aftercare following a more intensive inpatient or day hospital treatment. For both the outpatient and aftercare arms of the study, treatments were discriminable in that therapists implemented each of the treatments according to manual guidelines and rarely used techniques associated with comparison approaches. Participants received a high level of exposure to their study treatments, and the intended contrast in treatment dose between MET and the 2 more intensive treatments (CBT and TSF) was obtained. Alcoholics Anonymous involvement was significantly higher for participants assigned to TSF versus MET or CBT, whereas the treatments did not differ in utilization of other nonstudy treatments. Nonspecific aspects of treatment such as therapist skillfulness and level of the therapeutic alliance were comparable across treatment conditions.

Quality of life as an outcome variable in alcoholism treatment research.

Although a number of approaches to measuring alcohol consumption are available, these alone do not reflect the full range of changes that may be associated with response to treatment for alcohol abuse and dependence. What constitutes a sufficient index of response to alcohol treatment? At the very least, research should measure negative consequences of alcohol consumption, although they may be difficult to specify beyond the client's own perception. Associations between alcohol consumption and dimensions of life quality may be negative or positive in value and may be broadly or narrowly conceptualized, depending upon the aims of the study. Although models exist for the conceptualization and measurement of many aspects of quality of life in alcoholism and other fields, much remains to be specified. Still to be accomplished is a careful examination of the interrelationships between alcohol consumption and specific dimensions of life quality, particularly as these interrelationships are affected by time since treatment and client characteristics among other potential mediators and moderators. Project MATCH has attempted a broad assessment of dimensions of life quality beyond alcohol consumption. These variables are viewed as secondary, rather than primary, measures of treatment outcome. The extent to which Project MATCH's strategy was effective is a question that will be answered when we examine the interrelationships among the various dimensions of outcome and the differential effects of treatments on these outcome dimensions.