Alcohol and drug abusers' perceived reasons for self-change in Canada and Switzerland: computer-assisted content analysis.

Although many people recover from substance-use associated problems on their own, little is known about this phenomenon. The paper had two objectives: to use a new research method, computer-assisted content analysis, to understand alcohol and drug abusers' perceived reasons for self-change and to undertake a comparative evaluation across substances and cultures to validate previous findings about subjective appraisal processes. Three studies of natural recoveries of alcohol and drug abusers in two countries conducted tape-recorded interviews with 216 respondents. The taped responses were coded based on a content analytic dictionary approach using a computerized content analysis program. All three studies found several processes mediating the decision to change substance use. The computer content analysis confirmed a cognitive appraisal process regardless of the cultural setting or substance. The findings suggest that several procedures might have benefit in clinical interventions.

The relationship between thought suppression and smoking cessation.

Intrusive thoughts (e.g., anxiety, depression, substance use) are among the most salient symptoms of clinical problems. Therefore, methods of thought suppression have received considerable attention. However, some studies have found that attempts to suppress thoughts precipitate an increase in thoughts. In the case of substance abuse, such thoughts could serve as cues for further use. This study examined the association between thought suppression and quitting smoking in a sample of current and ex-smokers. Using the White Bear Suppression Inventory (WBSI), scores were obtained for participants' level of thought suppression. Based on the idea that a greater tendency to suppress thoughts would make quitting smoking more difficult, it was hypothesized that unsuccessful quitters would have higher WBSI scores than smokers who had successfully quit. It was found that mean scores on the WBSI were significantly higher (P<.05) for smokers than ex-smokers. These findings suggest that a tendency toward thought suppression may increase the likelihood that attempts to quit smoking will be unsuccessful.

Cross-cultural evaluation of two drinking assessment instruments: alcohol timeline followback and inventory of drinking situations.

This article describes the psychometric characteristics of two major assessment instruments used in a World Health Organization (WHO) clinical trial: (a) Alcohol Timeline Followback (TLFB, which assesses daily drinking patterns), and (b) Inventory of Drinking Situations (IDS, which assesses antecedents to "heavy" drinking). Clients (N = 308) were outpatient alcohol abusers from four countries (Australia, Canada, Mexico, and Sweden). Generally, the Alcohol TLFB and IDS were shown to be reliable and valid with outpatient alcohol abusers in four countries, and in three languages. These results suggest that the Alcohol TLFB and the IDS can be used in clinical and research settings with Swedish-, Spanish-, and English-speaking alcohol abusers.

A comparison of a brief and long version of the Situational Confidence Questionnaire.

Assessing confidence to resist drinking in high risk situations is an important part of behavioral treatments for alcohol problems. The present study assessed the reliability and validity of the original 100-item Situational Confidence Questionnaire (SCQ) and of an 8-item brief version (BSCQ). Using a visual analog scale, the BSCQ asked respondents to report their confidence to resist urges to drink heavily using the original eight SCQ subscales (e.g., pleasant times with others, social pressure). Data were collected from 120 adult problem drinkers who voluntarily entered an outpatient alcohol treatment program. The comparability of the BSCQ and the SCQ-100 was evaluated through intraclass correlations between the eight subscales and comparison of both instruments' underlying factor structures. Correlation coefficients for the subscales ranged from 0.56 to 0.80. Both instruments showed similar, but not identical factor structures. The present results indicate that the BSCQ provides comparable information to the SCQ-100. Limitations, as well as the clinical advantages, of using the BSCQ over longer versions are discussed.

Does enhanced social support improve outcomes for problem drinkers in guided self-change treatment?

Although social support has been repeatedly identified as a strong correlate of recovery from alcohol problems, enhancing social support has seldom been a focus of treatment research. Married problem drinkers who were willing to have their spouses involved in their treatment were randomly assigned among two brief outpatient treatment conditions: directed social support (DS, n = 28) and natural social support (NS, n = 28). In both conditions the treatment in which the problem drinkers participated was an identical program of guided self-change, a cognitive-behavioral motivational intervention involving an assessment and four individual treatment sessions. Problem drinkers' spouses each attended two individual counseling sessions where they were informed about the counseling procedures. The conditions differed in that spouses in the DS group were encouraged to play an active role in helping their partner by being supportive and particularly by reacting to relapse episodes in a manner consistent with a relapse prevention model. One year follow-up found that participants in both groups improved significantly from pretreatment to the end of treatment, and that the gains were maintained over follow-up. The two groups did not differ significantly from one another at any point in time. Possible explanations for the results include that (a) the baseline level of social support in this population may have created a ceiling effect, and (b) the prognosis for this population may be so positive that it is difficult to demonstrate significant enhancement of outcomes.

Stepped care as a heuristic approach to the treatment of alcohol problems.

A stepped care approach to treatment decisions for alcohol problems consists of the application of decision rules derived from practice in other areas of health care. The treatment used should be (a) individualized, (b) consistent with the research literature and supported by clinical judgment, and (c) least restrictive but still likely to be successful. Used in this way, stepped care emphasizes serving the needs of clients efficiently but without sacrificing quality of care. Issues concerning stepped care are discussed, and the application of a stepped care approach to alcohol treatment services is described.

Natural recovery from alcohol and drug problems: methodological review of the research with suggestions for future directions.

AIMS: The methodology of studies that reported data on individuals who recovered from an alcohol or other drug problem (cigarette smokers were excluded) without formal help or treatment were reviewed. DESIGN/MEASUREMENTS: Potential studies were identified (a) through computerized literature searches, (b) by reviewing references from key publications and (c) by correspondence with researchers in the field. Studies had to (a) be in English, (b) be published, in press, or presented before the end of 1997, (c) report original results or be part of an original survey and (d) separately report respondents whose recoveries were and were not attributable to treatment. No case studies were included. Eligible studies were evaluated with respect to meeting criteria for (a) natural recovery, (b) methodological rigor and (c) reporting demographic and substance abuse history variables. FINDINGS: Until 1997 only 38 articles (40 different respondent samples) met the inclusion criteria for this review. This small number of studies is not surprising, as natural recovery from substance abuse is a relatively new area of study. Moreover, the majority of the 38 articles were published in the past 8 years. For most studies, descriptions of the respondent samples at pre- and post-recovery were seriously deficient. Alcohol was the most studied drug, with heroin a distant second. Low-risk drinking (78.6%) and limited drug use (46.2%) were commonly reported outcomes in natural recovery studies. CONCLUSIONS: Based on this review, future natural recovery studies should: (a) report respondents' demographic characteristics at the time of their recovery; (b) describe respondents' pre-recovery problem severity; (c) explore in some depth what factors, events or processes are associated with the self-change process; (d) provide corroboration of respondents' self-reports; (e) examine factors related to the maintenance of recoveries; (f) conduct interviews with individuals who have naturally recovered from cocaine, marijuana and polydrug abuse; (g) include a second interview at a later time to examine stability of natural recoveries; and (h) require a minimum 5-year recovery time frame.

Evaluation of the Yale-Brown Obsessive Compulsive Scale (YBOCS-hd) for heavy drinking with mild to moderately dependent alcohol abusers.

BACKGROUND: Many similarities have been noted between urges and desires to drink heavily and obsessive-compulsive disorders (OCD). Based on such similarities, Modell et al. (1992) developed the Yale-Brown Obsessive Compulsive Scale for heavy drinking (YBOCS-hd), a modified version of YBOCS, to assess obsessions and compulsions related to heavy drinking. Evaluation of the YBOCS-hd has been limited to more severely dependent alcohol abusers. METHODS: The present study used a self-administered version of the YBOCS-hd to evaluate (1) the severity of drinking-related obsessive compulsive symptoms with mild to moderately dependent alcohol abusers (problem drinkers), and (2) whether end-of-treatment changes in YBOCS-hd scores would be related to within-treatment functioning. RESULTS: Results indicated that problem drinkers have lower alcohol-related Obsessive and Compulsive subscale scores than did more severely dependent drinkers, but higher scores than did non-problem drinkers, supporting the construct validity of the YBOCS-hd. In addition, at the end of treatment, the YBOCS-hd scores of alcohol abusers who drank at low-risk levels during treatment were significantly lower than the scores of those who drank at high-risk levels. Lastly, exploratory factor analysis did not provide support for the two purported YBOCS-hd subscales (Obsessive, Compulsive). Instead, the analysis yielded a single general factor and a second factor that contained two questions measuring heavy drinking. CONCLUSIONS: Despite the fact that total YBOCS-hd scores covaried with drinking, neither the total YBOCS-hd pretreatment score nor the two subscale scores predicted functioning at the end of treatment. The present results call into question the utility of the YBOCS-hd, because a single item measuring the heaviness of drinking was as useful as the total YBOCS-hd and its two subscales in relating changes during treatment to end-of-treatment functioning for problem drinkers. However, although the YBOCS-hd does not predict changes in drinking, it may have value as an indirect measure of drinking in situations where direct measurement of alcohol consumption is undesirable (i.e., direct measurement might be reactive). Because the present findings are derived from problem drinkers, further research is needed to confirm the factor structure of the YBOCS-hd with clients who represent a broader range of alcohol problem severity.

Utility of liver function tests for screening "alcohol abusers" who are not severely dependent on alcohol.

This study evaluated the utility of using liver function tests to identify low dependence outpatient "alcohol abusers" (N = 253) and for evaluating changes in their drinking over the course of treatment. Despite drinking at levels considered to pose a health risk (i.e., drinking on 72% of all days in the year prior to treatment and averaging 6.3 drinks per drinking day), nearly two-thirds had normal liver function tests at treatment entry. It is concluded that for problem drinkers the cost of using liver function tests outweighs the benefits.

Alcohol abusers who want to quit smoking: implications for clinical treatment.

Although most alcohol abusers are dependent on nicotine, studies of such individuals have been scarce. Consequently, little information is available for advising clients who wish to consider resolving both problems. Clients entering an outpatient alcohol treatment program who were also current smokers were asked about their temporal preferences for changing their alcohol and cigarette use. Over three-quarters of alcohol abusers who were also smokers when asked said they would be willing to consider stopping smoking during or after treatment for an alcohol problem. Individuals who were interested in quitting smoking cigarettes while in treatment for an alcohol problem were different from those who did not want to stop smoking, and such differences may influence their ability to successfully address both problems together. Compared to those who preferred to change their drinking first then address their smoking, those who said they would be willing to address both problems (i.e. smoking and drinking) together in treatment were not only considerably more likely to think that quitting smoking would affect quitting drinking, but also more likely to be planning to quit smoking in the next six months. These results suggest that some individuals whose alcohol problems are not severe and who also smoke cigarettes will be more receptive to a dual recovery approach than others. In the absence of research findings, health care practitioners who encounter individuals who drink heavily and smoke cigarettes should at a minimum explore the option of dual cessation with their clients. The clinical and research implications of the present results are discussed.

Evaluation of the readiness to change questionnaire with problem drinkers in treatment.

Prochaska and DiClemente's (1982, 1983) readiness to change model proposes that people resolve health-related concerns by working through a qualitative progression of distinct motivational stages. The present study examined the responses of 66 (44 males, 22 females) mildly dependent outpatient alcohol abusers to the Readiness to Change Questionnaire, a scale developed to classify individuals according to their motivational stage. It has been suggested that the RTCQ may have applicability to problem drinkers in treatment. Reliability analyses conducted on the questionnaire's three subscales resulted in alpha coefficients of .30 for the Precontemplation subscale, .52 for the Contemplation subscale, and .76 for the Action subscale. The low internal reliability for the first two subscales does not support the use of this questionnaire in a treatment context at this time. Further studies are needed to refine the subscales. A psychometrically sound measure, once developed, would provide guidance in treatment matching.

Awareness of self-change as a pathway to recovery for alcohol abusers: results from five different groups.

Results from several recent studies, particularly general population surveys, reveal that self-change (recovery from alcohol problems without treatment) is a major pathway to recovery from alcohol problems. Results from five different groups of subjects, however, suggest that most people are unaware of this fact. Reasons for this lack of awareness are discussed, and suggestions are made as to the implications of increasing the public's awareness about self-changes as a way of recovering from alcohol problems.

Problem drinkers: evaluation of a stepped-care approach.

The present study evaluated a stepped-care model for the treatment of problem drinkers; those not severely dependent on alcohol. The initial treatment consisted of a motivationally based, four-session outpatient treatment. Based on previous research, treatment nonresponders were defined as having consumed more than 12 drinks per week between the assessment and third session. Six-month follow-up interviews were conducted on three groups of problem drinkers: (1) those who responded to the initial intervention (n = 67); (2) those who did not respond to the initial treatment (n = 36); and (3) those who did not respond to the initial treatment and received a supplemental intervention (n = 33). The last two groups were used to evaluate whether providing treatment nonresponders with an additional "step" would improve treatment outcomes. The primary dependent measures were posttreatment percent days abstinent and posttreatment drinks per drinking day. Results suggested that (1) within treatment drinking can help identify treatment nonresponse in stepped-care models; (2) the supplemental intervention did not influence posttreatment drinking; (3) treatment responders and nonresponders sought additional help at the same rate. The present study is the first study on stepped-care for alcohol treatment and provides a methodology for evaluating stepped interventions. Recommendations for future research in this area include more attention to assessing the needs of treatment nonresponders and help seeking behavior of both responders and nonresponders after an initial intervention.

Factors affecting agreement between alcohol abusers' and their collaterals' reports.

OBJECTIVE: Because of their low cost and ease of use, collaterals' reports are the most frequent source of independent corroboration with alcohol abusers' self-reports of drinking and related events. Although several reviews have shown that we can have confidence in the accuracy of alcohol abusers' reports of their drinking and in the use of collateral reports as an independent validity criterion, neither data source is error free. This study examined factors that influence the level of agreement between collaterals' and alcohol abusers' reports. METHOD: Using data from a study of natural recoveries from alcohol-related problems, this study examined how agreement between 120 alcohol abusers' (79.2% male) and their collaterals' reports varied as a function of collateral type and of the collaterals' ratings of their confidence in the accuracy of their reports of the subjects' drinking and related behaviors. Collaterals' awareness of nonalcohol-related levels was also examined. RESULTS: The best agreement occurred for reports from alcohol abusers' spouses who were fairly confident about the information provided. For all variables, some proportion of collaterals respond to demand characteristics of the interview by providing very specific information about subjects' behavior yet admit to being unsure of this information. CONCLUSIONS: Collaterals who are fairly sure of the information they provide are the preferred informants to corroborate alcohol abusers' reports of drinking and related behaviors. In some cases the best collaterals are spouses who are fairly sue of the information they reported. It is also recommended that treatment outcome studies should accept reports only from collaterals who are confident about the information they report.

Alcohol treatment outcome methodology: state of the art 1989-1993.

This article reviews the 61 alcohol treatment outcome studies published from 1989-1993 with respect to methodology. Although better assessment of subjects' pretreatment characteristics was noted, a minority of studies met even the basic requirements of experimental studies. Further, some reversals of methodological progress were observed in several areas, particularly in collecting outcome data from multiple sources. It is suggested that funding agencies and journal editors require that submissions meet minimum standards for adequate outcome evaluation.

Toward a stepped care approach to treating problem drinkers: the predictive utility of within-treatment variables and therapist prognostic ratings.

AIMS: Cost containment, a central issue in current health planning, encourages the use of brief interventions. Although brief interventions for problem drinkers have proved successful, a portion of such individuals do not change their alcohol use during treatment. DESIGN: Repeated measures design (pre-treatment, within-treatment and 6 months post-treatment). SETTING AND PARTICIPANTS: To identify individuals at risk for continued problem drinking, predictors of post-treatment drinking were examined for 212 problem drinkers who presented for treatment in an outpatient treatment clinic. INTERVENTION: All participants completed a brief cognitive behavioral motivational intervention. MEASUREMENTS: At the pre-treatment assessment demographic, drinking pattern, severity of dependence and other cognitive variables (e.g. self-efficacy, goal choice) were collected. Within-treatment, drinking pattern and cognitive variables such as self-efficacy and goal choice were again measured. FINDINGS: Regression analyses showed that therapist prognosis ratings contributed significantly to the prediction of outcome even when pre-treatment variables were controlled. However, when within-treatment variables were included in the prediction, variables such as within treatment drinking eliminated the predictive utility of therapist prognosis ratings. This pattern held for both percentage of days abstinent and drinks per drinking day at a 6-month follow-up. CONCLUSIONS: It is suggested that a stepped care approach based on prediction models that include clients' within-treatment response can be applied to the treatment of problem drinkers who show little initial response to treatment.

Fostering self-change among problem drinkers: a proactive community intervention.

This paper describes the rationale and design for a recently implemented study involving a community-based intervention designed to foster self-change for individuals who otherwise would be unlikely to seek formal help or treatment for their alcohol problem. The study is based on research examining natural recovery processes with alcohol abusers and on clinical trials using a Guided Self-Change model of treatment with problem drinkers. Advertisements and mailed pamphlets are used to solicit individuals who wanted to change their drinking on their own using self-help materials. Respondents are screened and, if eligible, are randomly assigned to two conditions: Guided Self-Change (GSC) or Educational Materials Control (EMC) (projected N = 788): All subjects complete and mail in several brief assessment forms. Subjects in the GSC group receive advice and personalized feedback based on their assessment answers. Subjects in the EMC group receive educational pamphlets prepared for general medical and mental health settings. Subject characteristics and drinking-related history variables for the first 10% of the sample are presented. Subjects will be followed up at 12 months following the intervention.