Types of alcoholics, II. Application of an empirically derived typology to treatment matching.

Data from 79 male alcoholics who were randomly assigned to either coping skills training or interactional group psychotherapy were used to replicate a multidimensional, empirically derived typology and to evaluate the typology's usefulness in matching patients to treatment. Consistent with previous cluster analysis research, indicators of risk for alcoholism, alcohol dependence, drinking history, and psychopathological impairment distinguished alcoholics along two broad dimensions of vulnerability and severity, with one subtype (type B alcoholics) manifesting an earlier onset of problem drinking, more familial alcoholism, greater dependence on alcohol, and more symptoms of antisocial personality than the other subtype (type A alcoholics). Analyses of outcome indicated that type A alcoholics fared better in interactional treatment and more poorly with coping skills training. Conversely, type B alcoholics had better outcomes with the coping skills treatment and worse outcomes with interactional therapy. Differences in treatment response were maintained for 2 years from the beginning of aftercare treatment.

Issues in the definition and diagnosis of alcoholism: implications for a reformulation.

This paper examines definitions of alcoholism from theoretical and historical points of view. It begins with a review of definitions of alcoholism from the 19th century to the present, giving particular attention to medical approaches, psychiatric formulations, behavioral concepts, and definitions proposed by the American Psychiatric Association and the World Health Organization. It is concluded that current definitions differ widely in scope, the meanings attached to words like disease and disorder, the criteria for including signs and symptoms as essential characteristics, and the potential uses of the definitions. Based on these considerations, the practical issues of developing and applying clinically useful diagnostic procedures are discussed. The paper concludes with a discussion of diagnostic issues that should be considered in any effort to improve clinical identification, treatment planning and international communication.

Is Marlatt's relapse taxonomy reliable or valid?

The Relapse Replication and Extension Project (RREP) has failed to provide empirical support for Marlatt's relapse taxonomy. Neither the reliability of the original Marlatt coding system nor its predictive or construct validity was supported by this group of studies. The present commentary explores a number of possible reasons for the generally negative outcomes. These findings should certainly lead to a re-evaluation of Marlatt's relapse taxonomy and its operationalization. Nevertheless, despite the negative results, there are a number of reasons why the general Relapse Prevention concept is likely to survive in some form: it has been widely adopted and imitated clinically, key elements of the taxonomy are often focal points of treatment, and clinical research studies have repeatedly supported some elements of the taxonomy (e.g. negative emotional states, social pressure, interpersonal conflict, positive emotional states and temptations/urges). The RREP also evaluated some modifications of the original taxonomy as well as the use of more structured assessment instruments, and some of these provided more promising results. Further developments will need to take into account both research needs for greater precision, most likely through the use of more structured assessment instruments, and clinical needs for richness of detail and sensitivity to a wide variety of life circumstances.

Validity of the SCID in substance abuse patients.

Structured or semi-structured interviews, including the Structured Clinical Interview for DSM-III-R (SCID), are used widely to maximize the reliability and validity of psychiatric diagnoses. Although the reliability of such interviews appears adequate, there has been little effort to evaluate their validity. In a sample of 100 substance abuse patients, we evaluated the concurrent, discriminant and predictive validity of SCID substance use diagnoses, as well as co-morbid disorders that occur commonly among these patients. The validity of current and life-time substance use diagnoses obtained by a research technician using the SCID was good; it was moderate for antisocial personality disorder and major depression and poor for anxiety disorders. Although accurate diagnosis of substance use disorders in substance abuse patients can be accomplished by a research technician, the diagnosis of co-morbid psychiatric disorders requires either additional expertise or the use of a diagnostic instrument specially designed for that purpose.

Matching alcoholics to coping skills or interactional therapies: posttreatment results.

This study tested the hypothesis that patients could be matched to effective treatments on the basis of certain pretreatment characteristics. Specifically, it was hypothesized that those Ss who showed more sociopathy, more psychopathology, and greater neuropsychological impairment would have better outcomes when treated with coping skills training and, conversely, that those with less impairment in these areas would have better outcomes with interactional treatment. Ninety-six male and female Ss were recruited from an inpatient alcoholism treatment program and randomly assigned to 1 of these 2 types of aftercare group treatment. Linear and logistic regression analyses partially confirmed the hypotheses. Coping skills training was more effective for Ss higher in sociopathy or psychopathology, and interactional therapy was more effective for Ss lower in sociopathy. Generally, both treatments appeared equally effective for Ss lower in psychopathology. Contrary to expectations, those more neuropsychologically impaired appeared to have better outcomes after interactional therapy.

Matching alcoholics to coping skills or interactional therapies: two-year follow-up results.

Ninety-six subjects were recruited from an inpatient alcoholism treatment program and randomly assigned to aftercare group treatment with either coping skills training or interactional therapy. Survival analyses using 2-year outcome data provided evidence for the durability of matching interaction effects. The data supported a priori hypotheses that individuals scoring high on measures of sociopathy or global psychopathology have better outcomes in coping skills treatment, whereas patients low on these dimensions have better outcomes in interactional treatment. Contrary to the original hypothesis, patients with cognitive impairment had better outcomes in interactional treatment, and patients without cognitive impairment did better in coping skills treatment.

Validity of the longitudinal, expert, all data procedure for psychiatric diagnosis in patients with psychoactive substance use disorders.

The longitudinal, expert, all data (LEAD) procedure has been employed as a criterion for the assessment of the procedural validity of diagnostic instruments. This study evaluated the procedure's concurrent, discriminant and predictive validity. Interview and questionnaire data obtained from 100 individuals in a substance abuse treatment program were used to assess current and lifetime substance use disorders and common comorbid disorders. An experienced, doctoral-level clinician formulated LEAD diagnoses for each patient, based on an initial interview, ongoing clinical contact and the results of the research assessment and all available clinical records. LEAD-derived substance use diagnoses showed good concurrent, discriminant and predictive validity. The validity of comorbid diagnoses obtained using the LEAD procedure was generally fair to good. Comparison with diagnoses based only on the clinician's unstructured initial interview showed that the availability of additional data enhanced diagnostic validity. Diagnoses derived by a research technician using the Structured Clinical Interview for DSM-III-R showed validity comparable to that of LEAD diagnoses. To enhance its diagnostic validity, applications of the LEAD standard should include a structured interview. Other variations in the application of the LEAD standard, including a longer evaluation period, may also enhance its performance as a diagnostic criterion measure.

Implementing treatment and protecting the validity of the independent variable in treatment matching studies.

Treatment matching research is predicated on heterogeneity among subjects and their differential response to treatments. The sine qua non of a treatment matching study is the integrity of the treatment variable, since detection of client-treatment interactions requires delivery of treatments that are highly specific, consistent and distinct. Matching research thus presents particular challenges in treatment implementation, as greater heterogeneity in subjects may generate a broader array of problems than study treatments are designed to address, leading to several potential threats to treatment integrity. Moreover, as practiced outside of research settings, treatments for alcoholism are marked by ideological heterogeneity and a lack of purity across approaches. In this article we describe the strategies used in Project MATCH to protect treatment integrity while treating a large and heterogeneous sample of alcoholics in a number of geographically distant sites. These include: strategies for treating a variety of alcoholics within a single treatment approach; development of clinical care guidelines and clinical deterioration criteria; specification of treatments in manuals with minimization of overlapping active ingredients; selection criteria for therapists intended to enhance both generalizability of findings as well as treatment integrity; and extensive therapist training and monitoring.

Process assessment in treatment matching research.

A complete understanding of the effects of treatment requires an examination of the process by which the treatment produces the outcome as well as a thorough assessment of the outcomes. Process assessment assumes even greater importance in matching research than in other types of treatment research, since client-treatment interactions are hypothesized to be moderated or mediated by specific treatment components. The role of process assessment in treatment matching research is examined using Project MATCH as an illustrative example. Four process domains, including dose of treatment, within-session treatment activities, the therapeutic alliance and extra-session activities, are described in terms of their role as mediators or moderators of treatment outcome and the perspectives by which they are assessed in Project MATCH.

Issues in the selection and development of therapies in alcoholism treatment matching research.

There are a large number of possible approaches to the treatment of alcohol abuse and dependence. From a practical and methodological standpoint, however, only a limited number of interventions can realistically be included in research studies of treatment matching. A key question in planning studies of matching is what treatments to include. The recent book by Beutler and Clarkin on systematic treatment selection in general psychotherapy provides a framework within which to discuss alcoholism treatment matching and the criteria applied to decisions concerning (1) modes of treatment, (2) treatment format, (3) specific therapeutic strategies and the (4) treatment setting. The methodological and practical issues raised and the decisions reached in Project MATCH are presented in each of these areas. The therapies chosen for Project MATCH, based on these criteria, are described.

A chronological review of empirical studies matching alcoholic clients to treatment.

During the past 20 years researchers have become increasingly interested in exploring the benefits of differential assignment of alcoholics to treatments based on client-specific characteristics, rather than searching for a single "most effective" intervention for all clients. Thirty-one empirical studies on "client-treatment matching" are reviewed, particularly from the perspective of how research methodology in this area has evolved. In addition, general observations are provided on how research methodology on this topic can be further enhanced. Finally, several promising interactions between client characteristics and particular interventions are noted, based on empirical studies to date.

Enhancing participation in substance abuse treatment using an incentive system.

A contingency management system is described for enhancing participation in an inpatient chemical dependency rehabilitation program. The system employs reinforcers that are readily available in a residential milieu and makes receipt of them contingent upon appropriate patient behaviors. The behaviors include arranging aftercare treatment, involving family members in the treatment process, appropriate participation in ongoing treatment activities, and assisting with unit chores. A patient's status within the program is first regulated on a noncontingent basis, after which an accumulation of nine specified accomplishments results in the acquisition of a number of privileges. Accumulation of three demerits, given for inappropriate behaviors, results in a status reduction that can only be restored by completing ten additional behaviors. Improvement in patients' program involvement was documented in a number of areas, with a concomitant reduction in resistance to treatment. The system also resulted in an improvement in staff's charting of patients' behavior.

Utility of a brief cognitive screening instrument in substance abuse patients: initial investigation.

The ability of the Cognitive Status Examination (CSE), a brief neuropsychological screening instrument, to detect cognitive impairment in substance abusing patients was evaluated in 200 consecutive admissions to a drug/alcohol rehabilitation unit. While a significant proportion (25%) of patients screened were classified as impaired using the cutoff derived in the original study, agreement with an independent neurological impairment classification was much lower than that reported in the earlier work. Possible reasons for this discrepancy are discussed, including the relatively subtle nature of cognitive impairment in substance abusing patients. Implementation of regular screening did seem to heighten staff sensitivity to cognitive impairment in this sample. Alternate methods of determining the usefulness of cognitive screening tools (e.g., relationship to treatment relevant skills) are also discussed.

A comparison of methods for assessing sociopathy in male and female alcoholics.

This study compared four methods for assessing sociopathy in alcoholics. A total of 79 male and 39 female inpatient alcoholics were administered the following scales: (1) the NIMH Diagnostic Interview Schedule (DIS) which provides a DSM-III diagnosis of antisocial personality disorder (APD) and an antisocial symptom count; (2) the Hare Psychopathy Checklist; (3) the Socialization scale from the California Psychological Inventory (CPI-So); and (4) the MMPI-168 Psychopathic Deviate (Pd) scale. Factor analysis for the four continuous measures (DIS symptom count, Hare, CPI-So, MMPI-168 Pd) resulted in a one factor solution, implying that all four scales measure a single underlying construct. The CPI-So had the highest loading, indicating that this measure has the strongest degree of association with the underlying construct of sociopathy. Results of a discriminant function analysis indicated that only the CPI-So reliably discriminated between alcoholics diagnosed APD and non-APD by the DIS. These findings indicate that CPI-So is a valid and easily administered continuous measure of sociopathy in alcoholic patients.

Prospective matching of alcoholic clients to cognitive-behavioral or interactional group therapy.

OBJECTIVE: In earlier work, client sociopathy and global psychopathology were effective variables for treatment matching: clients low on both sociopathy and severity of psychopathology were likely to benefit from interactional group therapy, whereas those scoring high on either of these dimensions benefited more from a coping skills intervention. The present study assessed whether outcomes improve further when clients are assigned to group treatments prospectively based on a matching strategy derived from the previous findings. METHOD: All participants (N = 250, 66% men) met criteria for alcohol dependence or abuse. About half were prospectively assigned to either cognitive-behavioral (CB) coping skills training or interactional therapy, those with higher levels of psychiatric severity or sociopathy were given CB and those who were low on both dimensions were given interactional therapy. The other half were randomly assigned to those treatments, replicating the procedure of the earlier study. Outcome data were collected at the conclusion of treatment and at 3-month intervals for 1 year following. RESULTS: Prospective matching of clients to treatment did not produce superior drinking outcomes compared to random treatment assignment. Randomly assigned clients were more likely to be abstinent at the end of treatment, but this effect disappeared at later follow-ups. Prospectively matched clients had fewer negative consequences of drinking than did those assigned randomly (unmatched). Neither sociopathy nor psychiatric severity was particularly effective for matching. CONCLUSIONS: The matching effects from our previous study were not replicated. Nevertheless, prospective matching did reduce the negative consequences of drinking, consistent with our previous results.

Behavioral and cognitive-behavioral treatments for alcoholism: research opportunities.

This status report on behavioral and cognitive-behavioral treatments (CBT) for alcoholism is based on an article commissioned by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for a review of its treatment research priorities. A number of gaps in knowledge and consequent research opportunities were identified. Additional work on cue exposure is needed to identify the most potent cues for drinking, and strategies for reducing the impact of drinking cues. Regarding contingency management, there is need for further studies with alcoholics, investigation of reinforcement schedules, and exploration of maintenance factors. With respect to the community reinforcement approach (CRA), research should identify its most effective elements and ways to sustain gains following treatment. The mediating role assigned to coping skills in the cognitive-behavioral model needs to be substantiated, and the effectiveness of various coping skills components must be determined. Further studies of relapse prevention (RP) are needed to improve the system for classifying relapse episodes, and to identify the most effective interventions for each type of episode. Studies of behavioral marital therapy should include identifying active ingredients, and testing hypothesized mediators of change. Patient-treatment matching strategies may help to identify clients likely to benefit from these strategies. Finally, given the overlap among these approaches, it is likely that research along the lines suggested will impact several of them and lead to a consolidation of their most effective elements into a common treatment package.

Reactivity to alcohol cues and induced moods in alcoholics.

It has been theorized that respondent conditioning processes in part underlie desire for alcohol and thus contribute to relapse after alcoholism treatment. One implication of this theory is that the relevant conditioned responses could be eliminated by respondent extinction, in which the alcoholic patient is exposed to alcohol-related stimuli while being prevented from consuming alcohol. However, exteroceptive cues such as the sight and smell of alcoholic beverages are not always sufficient to elicit desire for alcohol. In view of this, it has been suggested that interoceptive cues, such as mood states, may also play a role in eliciting desire for alcohol. To test this, eight alcoholic subjects were induced to experience negative or neutral moods on four separate days, and then exposed to the sight and smell of their favorite alcoholic drink, and to a neutral stimulus (seltzer water), in a within-subjects design. Results from this work indicate that: (a) negative moods can be reliably induced in the laboratory as confirmed by subjects' reports; (b) exposure to alcohol cues had no effect on desire for alcohol while subjects were in a relaxed, neutral mood state; (c) the presence of negative mood states alone appeared to be sufficient to elicit desire for alcohol in some subjects, regardless of whether alcohol or water was presented. These data argue that negative mood states may cue desire for alcohol independent of other cues. The data also suggest that reactivity to alcohol cues may be substantially reduced by relaxation.

Relationship between role-play measures of coping skills and alcoholism treatment outcome.

Alcoholic clients were given role-play tests, involving various social and drinking-related scenarios, before and after two types of aftercare treatment. The assessments were used both to evaluate the effects of treatment and to determine whether any dimensions of pretreatment role-play performance interact with treatment type to predict treatment outcome. Eighty-nine patients were randomly assigned to aftercare group treatment involving either interactional therapy or coping skills training. Clients in both treatments experienced declines in their urge to drink during the role-play scenes from pre- to posttreatment, and these declines were related to reductions in heavy drinking. Three pretreatment role-play variables interacted with type of treatment to predict outcome: observer-rated skill, observer-rated anxiety, and self-reported urge to drink. In general, those patients who did better in the role plays had better drinking outcomes following interactional therapy. Those who experienced more difficulty in the role plays fared best with coping skills training. The results suggest that role-play measures could be used for patient-treatment matching, although it remains to be determined whether they will be superior to more easily assessed patient characteristics.

Facilitation and suppression of responding under temporally defined schedules of negative reinforcement.

Two parameters for scheduling aversive stimulus presentations were studied systematically by specifying concurrent and independent probabilities of electric shock delivery for the occurrence and for the non-occurrence of a lever-press response. After preliminary training on a free-operant shock-avoidance schedule, 16 rhesus monkeys were divided into four groups, each group being assigned one shock distribution on a continuum from fixed interval to a widely ranging variable interval. Within groups, each subject was successively exposed to three values of response-dependence of shock delivery on a continuum from response-independent shock to complete dependence of shock on response occurrence ("punishment"). Introduction of shock following avoidance training produced initial response facilitation followed by suppression. Responding during both the facilitation and suppression periods was maximal when the shock schedule was periodic and response independent. Responding decreased as the inter-shock intervals were made more variable across groups, and as shock delivery was made increasingly response dependent within individual subjects.

Measuring treatment process in coping skills and interactional group therapies for alcoholism.

An instrument designed to measure components of two distinct alcoholism aftercare treatments was developed and evaluated for reliability and validity. Trained judges reliably rated audiotaped samples of coping skills and interactional group therapy sessions. Coping skills groups engaged in significantly more education and skill training, problem solving, and role playing. Interactional groups showed more interpersonal learning, expression/exploration of feelings, and here-and-now focus. Groups that employed more education and skill training, less expression and exploration of feelings, and less here-and-now focus were associated with fewer members reporting subsequent drinking-related problems. None of the ratings of group activities was related to abstinence.