Table Of ContentThis is a volume in
PERSONALITY, PSYCHOPATHOLOGY, AND PSYCHOTHERAPY
A Series of Monographs, Texts, and Treatises
Under the Editorship of David T. Lykken and Philip C. Kendall
A complete list of titles in this series is available from the publisher upon request.
Treatment and Prevention
of Alcohol Problems
A Resource Manual
Edited by
W. Miles Cox
Psychology Service and Alcohol Research Laboratory
Richard L. Roudebush Veterans Administration Medical Center
and Department of Psychiatry
Indiana University School of Medicine
Indianapolis, Indiana
1987
ACADEMIC PRESS, INC.
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COPYRIGHT © 1987 BY ACADEMIC PRESS, INC.
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Library of Congress Cataloging in Publication Data
Treatment and prevention of alcohol problems.
(Personality, psychopathology, and psychotherapy)
Includes index.
1. Alcoholism—Treatment. 2. Alcoholism—Prevention.
3. Psychotherapy. I. Cox, W. Miles. II. Series.
[DNLM: 1. Alcoholism—prevention & control. 2. Alcoholism
-therapy. WM 274T7836]
RC565.T73 1987 616.86Ί06 86-10758
ISBN 0-12-194470-0 (alk. paper)
PRINTED IN THE UNITED STATES OF AMERICA
86 87 88 89 9 8 7 6 5 4 3 2 1
For my colleagues who work to treat and prevent alcohol problems.
Preface
With the enormous strides that have recently been made in our knowledge
and attitudes about alcohol problems, it is time now to pause. We need to
determine how the new information gained through clinical experience and
research can best be utilized for the treatment and prevention of these prob
lems. The present volume attempts to accomplish this purpose. As its title
indicates, the book is intended to be a resource manual for the treatment and
prevention of alcohol problems. The book is a manual in the sense that it
provides information and instruction, giving details about specific proce
dures to follow. It is a resource manual in the sense that it is not intended to
be a "one-shot" lesson on how to treat and prevent alcohol problems. The
book may well serve as the basis for implementing a treatment program, but
it is also intended to be a guide to which the clinical worker may refer as new
problems and questions arise with individual clients.
The contributors to the book represent the major innovators of treatment
and prevention programs for alcohol problems. Their chapters are organized
into four major parts. Part I deals with initiating treatment. Under this
rubric, Michael Liepman and Ted Nirenberg give guidelines to beginning
treatment of persons with alcohol problems, focusing on inpatient programs
that involve patients' families. Kenneth Wanberg and John Horn present
guidelines for assessing whether or not a person has an alcohol problem that
needs treating and the various factors that comprise the problem if one exists.
David Knott, James Beard, and Robert Fink discuss the medical aspects of
alcohol problems, describing the medical symptoms that characterize the
various stages of an alcohol problem and how these symptoms should be
attended to.
Part II proceeds with specific treatment techniques. Diane Riley, Linda
Sobell, Gloria Leo, Mark Sobell, and Felix Klajner discuss various behav
ioral treatments for alcohol problems and compare the relative efficacy of
behavioral and nonbehavioral approaches. Susan Curry and Alan Marlatt
present their program for preventing relapses following treatment, a pro
gram which aims to build clients' self-confidence, self-efficacy, and self-con
trol during its three respective phases. Next, Eric Klinger discusses mental
xiii
xiv Preface
imagery and logotherapeutic techniques that have been used enthusiastically
by a substantial number of clinicians as a supplement to other procedures for
helping persons to overcome their alcohol problems. Richard Thoreson and
Frank Budd discuss group therapeutic procedures for persons with alcohol
problems, giving special attention to the self-help groups administered by
Alcoholics Anonymous (AA) and suggesting ways in which professionals
and AA can work better together. The concept of craving for alcohol is
central to AA's disease model of alcoholism, but in the final chapter of Part
II, Laurence Baker, Ned Cooney, and Ovide Pomerleau discuss craving from
an empirical rather than a disease perspective, describing the physiological
indices of craving and therapeutic procedure to deal with it.
Part III deals with associated problems and special populations. Here,
Timothy O'Farrell discusses his techniques for resolving marital and family
problems associated with alcohol problems, including procedures to moti
vate clients to change, to bring about changes, and to maintain changes that
have been effected. Next, Edith Gomberg considers the sexual and gender
problems that are frequently interrelated with alcohol problems, providing
recommendations for clinicians who work with persons with both alcohol
and sexual/gender problems. Finally in Part III, Joan Weibel-Orlando de
scribes culture-specific treatment modalities, highlighting her work with
native Americans and suggesting ways to match particular clients with the
most appropriate treatment modality.
The focus of Part IV is on early intervention and prevention. Martha
Sanchez-Craig, Adrian Wilkinson, and Keith Walker describe their second
ary prevention program, which identifies and treats drinking problems be
fore they become severe and offers clients alternatives to the traditional
disease model of alcoholism which mandates total abstinence. Peter Nathan
and Raymond Niaura review a variety of prevention efforts that have been
undertaken in the United States (ranging from programs for persons at risk
to those for persons with well-developed alcohol problems), with special
attention given to the employee assistance programs with which Nathan has
worked.
These chapters are not intended to be mere reviews of the relevant litera
ture. The procedures described are based on solid theoretical and empirical
foundations, and the book attempts to uphold the highest scholastic stan
dards. Nevertheless, a primary intent of the book is to instruct clinical
workers in what techniques are available to them and how these techniques
can be put to practical use. Accordingly, much of the writing is based on the
authors' own clinical experiences.
It is expected that the book will be useful to a variety of professionals:
psychologists, psychiatrists and other physicians, social workers, nurses, and
counselors, as well as to paraprofessional alcoholism counselors. The book
Preface xv
will also be appropriate as a text for courses dealing with alcohol problems. In
addition, many others should find the book helpful, especially those who
have had personal experience with alcohol problems and want to understand
and better help persons with these problems.
Many persons helped to make this book possible. I thank the contributors
for the time and effort that they put into writing their chapters. I am indebted
to William Miller, Peter Nathan, and Sharon Wilsnack for their invaluable
suggestions for the book when it was being planned. I am grateful to Joseph
Blount, Colleen Donagher, and Eric Klinger for their encouragement and
support during the preparation of the book. Finally, I acknowledge the
expert secretarial assistance of Yvonne Storck and Charlotte Syverson.
1
An Overview of Treatment and
Prevention of Alcohol Problems
W. MILES COX
Psychology Service and Alcohol Research Laboratory
Richard L. Roudebush Veterans Administration
Medical Center
and
Department of Psychiatry
Indiana University School of Medicine
Indianapolis, Indiana 46202
I. INTRODUCTION
The treatment and prevention of alcohol problems do not enjoy a favor
able history. Before the decade of the 1970s, persons with alcohol problems
were given very little attention by professional therapists, physicians, or
research scientists. Alcoholism had long been stigmatized as a problem asso
ciated mainly with the lower social classes (the stereotypical "skid-row
bum"), moral weakness, and lack of willpower. Professionals, moreover,
when they did work with alcoholics, did not have effective treatment tech
niques available to them; consequently, their endeavors were largely unsuc
cessful. In short, alcoholics were poorly understood, and they were not seen
as rewarding persons with whom to work.
The 1970s saw a dramatic change in this sad state of affairs. There was a
vast increase in governmental support of alcohol education, research, and
treatment that began with the establishment of the National Institute on
Alcohol Abuse and Alcoholism (NIAAA) in 1971. The consequences of the
NIAAA for the treatment and prevention of alcohol problems have been
far-reaching. Treatment facilities for alcohol problems have proliferated,
basic and applied research has burgeoned (Cox & Thornton, 1986), and
promising treatment techniques have been developed. Concurrent with the
ι
TREATMENT AND PREVENTION Copyright © 1987 by Academic Press, Inc.
OF ALCOHOL PROBLEMS: A RESOURCE MANUAL All rights of reproduction in any form reserved.
2 W. Miles Cox
progress in our knowledge about alcohol problems and how to deal with
them, people's attitudes about these problems have changed. It has become
increasingly recognized that persons from any socioeconomic status can
develop problems with alcohol, that these problems are not an indication of
moral weakness, and that there are effective treatments for them.
Our goal in this volume is to compile the latest techniques for treating and
preventing alcohol problems that have been identified through the trailblaz-
ing work of the preceding years. The book is divided into four sections as
follows:
II. INITIATING TREATMENT
In the first section, we deal with the initial phase of treatment. Here we
discuss how to begin treatment for persons with alcohol problems, how to
assess their problems, and how to deal with the medical complications re
lated to them.
In Chapter 2, Michael Liepman and Ted Nirenberg present guidelines to
begin treatment for persons with alcohol problems. They focus on inpatient
treatments that emphasize involvement of the patient's family, but much of
their advice is applicable to other forms of treatment as well.
Liepman and Nirenberg believe that two matters must be attended to
when alcoholic patients enter a treatment program. First, therapists need to
establish the affective tone of the therapeutic relationship that will prevail
throughout subsequent treatment. The relationship should be based on
warm, respectful, and empathic regard for the patient, but it should be one in
which the therapist, not the patient, determines the direction that the treat
ment will take. Second, the therapist needs to assemble a "treatment team"
to work to solve the patient's problems with alcohol. The team should
comprise the various persons in the problem drinker's life who are con
cerned about his or her recovery but who may have unwittingly promoted
the problem drinking in the past.
According to Liepman and Nirenberg, a treatment plan should be devised
for the patient which should aim to make the positive aspects of sobriety
outweigh those of drinking. Such a plan should not be confined to patients'
drinking problems but should consider their medical, psychological, family,
and social problems as well. The treatment should focus on small, readily
achievable goals that lead to the achievement of larger goals. Finally, the
goals of treatment should be clearly specified in a treatment contract that
should be agreed upon by all persons involved in the treatment.
Before we can effectively treat a person's alcohol problems, we must first
carefully assess the problems. Thus, in Chapter 3, Kenneth Wanberg and
John Horn present guidelines for assessing whether or not a person has an
1. Overview 3
alcohol problem that needs treating and the various factors that comprise the
problem if one exists. Their multiple condition theory of alcoholism was
developed from years of research with the Alcohol Use Inventory (AUI), a
self-report instrument that yields scores on 18 primary scales, 6 second-order
factors, and a general factor.
The AUI provides detailed information about five facets of a person's use
of alcohol. (1) The various benefits that a person might derive from drinking,
including positive reinforcement (e.g., enhancement of sociability, mental
functioning, and positive emotions) and negative reinforcement (e.g., allevi
ation of stress, negative emotions, or somatic pain). (2) The person's manner
and style of drinking (e.g., gregarious versus solo, sustained versus periodic,
compulsive versus impulsive, and daily quantity). (3) Concepts indicating
disruptive consequences of drinking (loss of control over behavior, social
role maladaptation, physical and psychological withdrawal, disruptions in
emotions and relationships). (4) Self-concerns about disruptive conse
quences (anxiety and stress related to drinking and prior efforts to change the
pattern of drinking). (5) Acknowledgment of drinking problems (awareness
of impaired control and readiness for treatment). Combinations of these five
broad concepts define patterns of alcohol use that seem to point to various
types of alcoholism, some examples of which are discussed by Wanberg and
Horn.
Wanberg and Horn use these and various other measures to develop an
assessment profile for each patient. The ultimate purpose of this profile is to
match patients with available treatment modalities, such as those that are
described in subsequent chapters in this volume.
Wanberg and Horn's AUI can be used to assess medical problems result
ing from alcohol use—six primary medical factors have been identified.
However, these conditions are better identified with medical tests and exam
inations than with questionnaires. Hence, Chapter 4 by David Knott, James
Beard, and Robert Fink on the medical aspects of alcoholism tells us how
physicians assess and attend to medical problems related to alcohol abuse.
In Knott, Beard, and Fink's view, alcoholism can be seen as occurring in
three distinct phases: The acute phase includes intoxication, the withdrawal
syndrome, and toxic psychoses associated with alcohol use. The subacute
phase includes multiple medical and psychological problems associated with
alcohol use that often disguise themselves as disorders other than alcohol
ism. The chronic phase includes various social, psychological, and voca
tional problems that may be either antecedents or consequences of alco
holism.
To assist readers with the medical management of persons with alcohol
problems, Knott, Beard, and Fink carefully delineate the medical symptoms
that characterize each of the three stages. They give details about the body
systems that are affected by alcohol and provide guidelines for medical
