The Effectiveness of Treatment

Chapter 1 The Effectiveness of Treatment Janice M. Brown RTI International, Research Triangle Park, NC, USA

Synopsis Over the past decade, the treatment outcome research has consistently shown that there are effective treatment approaches for alcohol problems. These approaches include brief interventions and motivational interviewing, social skills training, community reinforcement, behavior contracting, relapse prevention and some aversion therapies. The commonality among these treatment approaches is the focus on actively engaging the client in the processes of suppressing use and teaching alternative coping skills. Research has also indicated that some of the more typical US treatment components are not effective and often show no improvement or worse outcomes when compared to well-articulated interventions. Pharmacologic agents that suppress the desire to drink have shown promise in reducing alcohol consumption. Naltrexone, an opiate receptor antagonist, has demonstrated effectiveness in several well-controlled studies. Withdrawal medications, psychiatric agents, and disulfiram show more limited effectiveness in US populations. There are a number of additional factors to consider when determining treatment effectiveness. Comorbidity of psychiatric diagnoses often complicates the picture and calls for a broader focus. Factors such as therapist characteristics and treatment setting frequently interact with treatment type. Research indicates that, in general, an empathic approach, in which one demonstrates respect and support of patients, appears to be most effective. The ongoing issue of inpatient vs. outpatient treatment remains equivocal. However, recent concerns over containment of health care costs supports a growing trend to favor outpatient approaches. The total economic costs of substance abuse remain high. Cost–benefit analyses show that the dollars invested in treatment serve to reduce overall health and social costs. The data indicate that including substance abuse treatment in a comprehensive health care plan can have a significant impact on savings.

The Essential Handbook of Treatment and Prevention of Alcohol Problems. Edited by N. Heather and T. Stockwell. © 2004 John Wiley & Sons Ltd. ISBN 0-470-86296-3.

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A growing body of literature points to the differential effectiveness of treatment approaches for alcohol problems (Finney & Monahan, 1996; Holder et al., 1991; McCaul & Furst, 1994; Miller et al., 1995, 1998). The increased emphasis on accountability in addictions treatment and the current efforts to contain health-care costs have resulted in demands for proof of efficacy for the various approaches. Treatment outcome research is used by practitioners and policy makers to determine the impact of specific treatments, with a particular emphasis on effectiveness and cost-offset. Effectiveness concerns whether specific improvements (e.g. family relationships, general functioning, emotional/physical health) have resulted from the application of a particular modality. Cost-offset refers to whether addictions treatment “pays” for itself by reducing subsequent expenses (e.g. reduced accidents, improvements in work performance). Over the past 40 years, treatments for alcohol problems have included insight psychotherapy, brief interventions and motivational approaches, psychosurgery, psychotropic and psychedelic medications, drug agonists and antagonists, electric shock, behavior contracting, marital and family therapy, acupuncture, controlled use, self-help groups, hospitalization, social skills training, hypnosis, outpatient counseling, nausea aversion, relaxation therapy, bibliotherapy, cognitive therapy and surgical implants. With such a diversity of approaches, an important issue is to determine efficacy while at the same time keeping client characteristics and cost-effectiveness at the forefront. This chapter provides a summary of treatment approaches with documented effectiveness as well as those with limited or no treatment efficacy. An economic evaluation of treatment approaches and predictors of treatment outcome are also included.

TREATMENT EFFECTIVENESS Research indicates that the majority of individuals drink less frequently and consume less alcohol when they do drink following alcoholism treatment (McKay & Maisto, 1993; Moos, Finney & Cronkite, 1990), although short-term outcomes (e.g. 3 months) are more favorable than those from studies with at least a year follow-up. Positive outcomes yield benefits for alcoholics and their families, as well as leading to savings to society in terms of decreased costs for medical, social and criminal justice services. Reviews of treatment outcome for alcohol problems have developed from early efforts to summarize findings (Bowman & Jellinek, 1941), to reports which derived outcome statistics (Emrick, 1974), to more recent publications examining efficacy in controlled studies with data on costeffectiveness (Finney & Monahan, 1996; Holder et al., 1991; Miller et al., 1995). Clearly, the literature suggests that a variety of approaches can be effective, some more than others because of the nature of the treatment and the intensity of the approach.

Treatment Approaches with Documented Effectiveness There are a number of treatment protocols for which controlled research has consistently found positive results, with more recent treatment outcome studies taking into account methodological quality (Miller et al., 1995) and cost-effectiveness (Finney & Monahan, 1996; Holder et al., 1991). Research continues to clarify the mechanisms for successful treatment outcome and provided here is a summary of interventions receiving strong support.

Brief Interventions and Motivational Interviewing Brief interventions (see also Chapter 8, this volume) vary in length from a few minutes to one to three sessions of assessment and feedback. The goals of brief interventions include

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problem recognition, commitment to change, reduced alcohol consumption and brief skills training. In a review of 32 controlled studies using brief interventions, Bien et al. (1993) reported that brief interventions were more effective than no treatment and often as effective as more extensive treatment. Individuals whose alcohol consumption is high, but who are not necessarily alcohol-dependent, are the primary targets for brief interventions. These approaches have several common components, including providing feedback, encouraging client responsibility for change, offering advice, providing a menu of alternatives, using an empathic approach and reinforcing the client. Brief interventions have also proved effective in reducing tobacco use and other drug use (Heather, 1998). In an atmosphere that promotes harm reduction, brief interventions offer an exciting alternative to more extensive treatment approaches. Motivational interviewing strategies (see also Chapter 7, this volume) seek to initiate a client’s intrinsic motivation to change (Miller & Rollnick, 1991). The approaches are based on the philosophy that ultimately it is the client who holds the key to successful recovery, once a commitment has been established. Understanding ambivalence as a central feature of a client’s hesitance to change and using encouragement and empathy to discover what makes it worthwhile to change are central. Tapping into values and providing feedback of risk and harm appear to strengthen clients’ commitment. A recent review of motivational treatment approaches offered overwhelming support for the use of these strategies in the early treatment of heavy drinkers in a variety of settings (Miller et al., 1998).

Social Skills Training Social skills training (see also Chapter 5, this volume) is usually incorporated into a more comprehensive “broad spectrum” approach and includes a focus on communication skills, such as assertiveness, for social relations. In general, the underlying assumption has been that drinking problems arise because the individual lacks specific coping skills for sober living. These deficits can include inability to cope with interpersonal situations as well as deficits in environmental (i.e. work) situations. The competent therapist will investigate the underlying sources of an individual’s vulnerability that can precipitate problem drinking. Research suggests that there are a number of domains for skills training: (a) interpersonal skills; (b) emotional coping for mood regulation; (c) coping skills for dealing with life stressors, and (d) coping with substance cues (Monti et al., 1995). The research evidence for the efficacy of social skills training in a comprehensive treatment package is strong and the core elements can be found in many other approaches. Compared with other approaches, social skills training yielded efficacy scores second only to brief interventions and motivational interviewing (Miller et al., 1998). Social skills training can be delivered individually or in group interactions and appears to be particularly appropriate for more severely dependent individuals who are more likely to experience serious psychopathology.

Community Reinforcement The community reinforcement approach (CRA) attempts to increase clients’ access to positive activities and makes involvement in these activities contingent on abstinence (Azrin et al., 1982) (see also Chapter 5). This approach combines many of the components of other behavioral approaches, including monitored disulfiram, behavior contracting, behavioral marital therapy, social skills training, motivational counseling and mood management. Some of the largest treatment effects in the literature have been associated with the community reinforcement approach (Miller et al., 1995). Compared to more traditional treatment approaches, the CRA has been shown to be more successful in helping inpatient

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or outpatient alcoholics remain sober and employed. Although community reinforcement is a more intense treatment approach, it is consistent with the basic philosophy of several other effective approaches. The ability to establish rewarding relationships, to focus on changing the social environment so that positive reinforcement is available, and to reduce reinforcement for drinking are emphasized with the community reinforcement and other approaches. The key appears to be helping the client to find and become involved in activities that are more rewarding than drinking.

Behavior Contracting Behavior contracting approaches are drawn from operant conditioning principles (Bigelow, 2001) and are used to establish a contingent relation between specific treatment goals (e.g. attending AA meetings) and a desired reinforcer. Written behavioral contracts are a way of actively engaging the client in treatment. Drinking goals are made explicit and specific behaviors to achieve these goals are outlined. Behavioral contracts are also useful for providing alternative behaviors to drinking. When evaluated either as an individual treatment approach or as part of marital therapy, behavior contracting consistently yielded positive results (Miller et al., 1995).

Aversion Therapies The primary goal of aversion therapies is to produce an aversive reaction to alcohol by establishing a conditioned response to cues associated with drinking (Drobes et al., 2001). The conditioning can be accomplished by using electric shock, apneic paralysis, chemical agents or imaginal techniques. Overall, results indicate that aversion therapies are effective in the short term with respect to a reduction in alcohol consumption (Miller et al., 1995). However, there appears to be a differential effect for the various forms of aversion. Nausea aversion therapy, in which a drug is administered so that nausea and emesis occur immediately following sipping and swallowing alcoholic beverages, has demonstrated a positive outcome in a number of studies and covert sensitization, which uses imaginal techniques to induce a conditioned aversion, has also shown promising findings, while apneic paralysis and electric shock have shown less encouraging results (Holder et al., 1991; Miller et al., 1995). In general, studies that have carefully defined procedures and which have documented the occurrence of classical conditioning have shown the strongest results.

Relapse Prevention Relapse prevention constitutes a behavioral approach with the goal of reducing the cues that precipitate relapse to alcohol (see also Chapter 6). Relapse can be triggered by stress, emotional states, craving or environmental stressors, and strategies that teach individuals how to cope with these events have demonstrated success in preventing relapse (Monti et al., 1995). Early approaches to treatment focused on initiating change, but paid little attention to strategies designed to maintain behavior change, with the result that relapse to drinking was the most common outcome of alcohol treatment. Subsequent research on the study of the determinants of relapse led to the development of interventions to increase self-efficacy and coping skills. Evaluations of the efficacy of relapse prevention efforts have yielded mixed results (Miller et al., 1995), but evidence suggests that interventions focusing on modifying cognitions related to failure and teaching individuals to quickly recover from lapses can be successful (Weingardt & Marlatt, 1998). A number of studies have demonstrated an interaction between self-efficacy and aftercare participation. Individuals with high self-efficacy who also participated more frequently in aftercare sessions had significantly better outcomes than all


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other groups, but aftercare participation improved treatment outcomes for those initially low in self-efficacy (Rychtarik et al., 1992). Similar results were found in a randomized trial of aftercare participation (McKay, Maisto & O’Farrell, 1993).Additional research has indicated that relapse prevention may be more effective for certain subtypes of alcoholics, and compliance may be indicative of a type of motivation for sustaining change (Donovan, 1998). From a harm-reduction perspective, relapse prevention efforts may serve to lessen the severity of relapse and minimize the harm associated with continuing alcohol use.

Summary Effective treatments appear to have several common strategies: suppressing use, eliciting motivation for change, and teaching alternative coping skills. Treatment approaches which actively engage the client in the treatment process appear to produce more positive outcomes. Furthermore, studies yielding positive outcomes may provide insight into both the etiology and mechanisms for resolution of alcohol problems.

Treatment Approaches with Limited Evidence of Effectiveness There are also a number of commonly used treatment approaches that do not show any evidence of effectiveness. These approaches comprise the largest number of treatment studies and are summarized below.

Insight Psychotherapy Psychotherapy seeks to uncover unconscious causes for a person’s alcohol problems. The goal is insight and psychotherapy is frequently studied as an adjunctive component to alcohol treatment. In general, studies do not reveal consistent positive results; in fact, the trend favors patients who did not receive psychotherapy (Miller et al., 1995).

Confrontational Counseling Confrontational interventions seek to break down defenses, particularly denial. Historically, confrontation has been considered an essential component of alcohol treatment, yet no studies have shown positive findings for approaches using confrontation (Finney & Monahan, 1996; Holder et al., 1991; Miller et al., 1995). In a controlled evaluation of therapist styles, Miller and colleagues (1993) found that confrontation yielded significantly more resistance and predicted poorer outcomes 1 year after a brief intervention. Miller & Rollnick (1991) suggested that confrontation is a goal rather than a procedure and that the occurrence of client resistance during a session should serve as immediate feedback for altering the therapeutic approach.

Relaxation Training The use of relaxation training or other stress reduction techniques has intuitive appeal but there is no scientific evidence to support their use (Miller et al., 1998). The impact of these findings supports the growing doubts that individuals drink to relieve stress.

General Alcoholism Counseling This type of counseling is usually directive and supportive but not specifically confrontational. One of the difficulties in evaluating general strategies is that they are frequently

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poorly defined and contrasted with additive components. However, the results of controlled evaluations indicate that alcoholism counseling is ineffective.

Education Education is without question one of the most common components of standard alcohol treatment programs. The intent is to convey information to help the person change drinking problems. Controlled studies of the use of educational lectures and films have consistently revealed negative findings (Finney & Monahan, 1996; Miller et al., 1998). There is no research support for the notion that alcohol problems result from a lack of knowledge and thus, no impact on outcome from providing the “missing” knowledge.

Milieu Therapy Implicit in the use of milieu therapy is the idea that recovery is aided by the place in which therapy occurs. The therapeutic atmosphere is itself thought to be beneficial. This idea is commonly associated with inpatient or residential programs which seek to promote an atmosphere of healing. Results of controlled research do not provide evidence to support residential/milieu therapy over less costly outpatient treatment and in fact, milieu therapy most frequently yields a less positive outcome when compared to a brief intervention (Miller et al., 1995, 1998).

Summary It is surprising that virtually all of the ineffective treatment approaches are precisely those offered in the typical US treatment program. Historically, the treatment of alcohol problems has been regularly followed by relapse; thus, one could assume that the “standard” treatment is ineffective. One common theme among ineffective approaches is their vague and imprecise description and, as Miller et al. (1995) have pointed out, well-articulated studies serve to promote treatment effectiveness.

Pharmacologic Approaches Pharmacological agents for the treatment of alcohol disorders (see also Chapter 4, this volume) have a long history and can be classified according to several major categories: (a) intoxication agents that reverse the effects of alcohol; (b) withdrawal agents; (c) psychiatric comorbidity agents, and (d) desire and compulsion agents. Much has been written about the effectiveness of disulfiram, and treatment outcome reviews generally agree that its effectiveness is limited. Likewise, withdrawal and psychiatric medications appear to be appropriate only for select populations of alcoholics, although this may not be applicable to countries other than the USA. The current research interest appears to be in medications that target the desire for alcohol. A potential area for study is the opioid system, which has been implicated in alcohol’s rewarding effects. Several studies have examined the effectiveness of naltrexone (ReVia), an opiate receptor antagonist, for decreasing alcohol consumption (O’Malley et al., 1992; Weinrieb & O’Brien, 1997). These studies have provided evidence of naltrexone’s effectiveness in decreasing alcohol craving and drinking days. Among patients who did return to drinking, those taking naltrexone and who received coping skills training were least likely to return to heavy drinking but the cumulative rate of abstinence was highest for patients who received naltrexone and supportive therapy.


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Naltrexone appears to be well-tolerated and effective in helping to stop resumption of binge drinking. There are presently more than a dozen studies examining the various aspects of using naltrexone as an adjunct to alcohol treatment. Future studies will need to determine more specific doses, the optimal duration of treatment, and whether subtypes of alcoholics would benefit from using naltrexone.

PATIENT–TREATMENT MATCHING An emerging trend in the early 1990s was to look beyond the issues of whether alcohol treatment worked or which treatment was most effective to the possibility that matching individuals to treatment based on individual characteristics would improve treatment outcomes. The idea of matching individuals to treatment was not new to the alcohol field and a review of matching studies indicated that some treatment approaches were, in fact, more effective than others for patients with certain characteristics (Mattson et al., 1994). In order to more clearly make recommendations about patient–treatment matching, the National Institute on Alcohol Abuse and Alcoholism initiated a multisite clinical trial entitled Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity). The goal was to determine whether different types of alcoholics respond selectively to particular treatment approaches. For example, cognitive-behavioral therapy was hypothesized to be more effective for patients with higher alcohol involvement, cognitive impairment and sociopathy. Twelve-step facilitation therapy was hypothesized to be useful for individuals with greater alcohol involvement and meaning seeking. Motivational enhancement therapy was hypothesized to be more effective for clients with high conceptual levels and low readiness to change (Project MATCH Research Group, 1997). Unfortunately, the results from Project MATCH challenged the view that patient– treatment matching would yield more positive outcomes. That is, there were few differences in outcomes when patients were randomly assigned to three distinctly different treatment approaches (Project MATCH Research Group, 1997). These results should be interpreted cautiously. Clearly, support for various treatment approaches does not mean that all clients will benefit from those approaches, or that no client ever benefits from less effective approaches. The trial demonstrated that regardless of treatment, patients had a greater number of abstinent days and a significant decrease in the number of drinks on drinking days. The results are further complicated by the nature of the study. This was the largest clinical trial ever conducted and each of the treatment approaches was manualized. The careful monitoring of treatment delivery, limiting attrition and delivering an adequate amount of treatment, may have served to make the modalities more similar than different with respect to therapist involvement.

PREDICTORS OF TREATMENT OUTCOME Treatment modality is not the only criterion that influences treatment outcome. The existence of other psychopathology, the specifics of treatment setting, and therapists’ effects all interact to determine treatment effectiveness. These additional variables are gaining interest in the alcohol treatment field and serve to guide treatment decisions.

Cormorbidity It is only within the last decade that dual-diagnosis patients have received research attention (see also Chapter 9, this volume). The rates of concurrent psychiatric disorders are

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high and a summary of recent research findings indicated that individuals with comorbid psychiatric diagnoses have poorer alcohol treatment outcomes (McKay & Maisto, 1993). This research takes on significance with respect to matching patients to more appropriate (e.g. psychotherapy) treatments. For example, Longabaugh et al. (1994) reported that alcoholics with antisocial personality disorder (ASP) had better outcomes with a cognitivebehavioral approach when compared to a relationship enhancement approach, and a second study indicated that alcoholics with ASP showed significant improvement in several drinking measures when treated with nortriptyline (Powell et al., 1995). Relatedly, recent studies have examined the effectiveness of treatment for individuals with comorbid drug dependence and reported an increased rate of relapse to both substances (Brower et al., 1994; Brown, Seraganian & Tremblay, 1993). Two of the challenges in treating dual-diagnosed patients are the differences in the nature of their problems and variability in their degree of motivation. Clearly there is a need for longitudinal studies of dualdiagnosis patients. Such research may identify the most effective treatment, provide insight into the temporal order of symptoms in those with anxiety or depressive disorders, and help to provide a theoretical base from which to develop appropriate treatment approaches.

Therapist Effects Therapist effects can have a significant impact on treatment outcome, yet few studies have controlled for them. The primary characteristics appear to be empathy and respect for patients (Najavits & Weiss, 1994). Given the variability in therapist’s styles, the alcohol treatment field has placed more of an emphasis on manualized treatment. Manual-driven treatment controls for variability and attempts to maximize the effects of successful therapist styles. Importantly, the success of brief interventions and motivational interviewing may well be due to the focus placed on empathy and support from the therapist. In fact, several studies identify therapist empathy as the pivotal factor in clients’ long-term treatment outcomes (Miller et al., 1998).

Treatment Setting and Treatment Type Alcohol treatment services are delivered in two primary settings: inpatient and outpatient. Inpatient services typically consist of short-term residential care and are often used for acute detoxification (Brown & Baumann, 1998). Inpatient care also provides intensive, highly structured treatment. Outpatient settings provide more long-term maintenance and can be either intensive, which have been modeled after day treatment programs, or typical, which usually include weekly group therapy sessions. Because of concern over rising health care costs, more emphasis is being placed on outpatient care for all phases of treatment (McCaul & Furst, 1994). Evidence from controlled clinical efficacy studies on the advantages of inpatient vs. outpatient treatment suggests little difference in effectiveness (Institute of Medicine, 1989; Miller et al., 1995). Other treatment variables, such as modality, duration of treatment and therapist characteristics, appear to have a more direct impact on treatment outcome. There is some evidence that comprehensive treatments are more effective than less intensive approaches (McKay & Maisto, 1993). However, these findings appear to be based on studies of more severe or dual-diagnosed alcoholics. In general, the data do not support intense inpatient treatment for all alcoholics, particularly those with uncomplicated alcohol dependence, but research is lacking on the role of these settings for individuals with


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additional diagnoses (McCrady & Langenbucher, 1996). With respect to treatment type, a number of approaches have been used, including 12-Step-based approaches, psychodynamic therapy and cognitive-behavioral interventions. Holder et al. (1991) concluded that brief interventions and cognitive-behavioral approaches appear to be more effective overall.

COST-EFFECTIVENESS Costs Associated with Treatment Whether alcohol treatment services are cost-effective is a fundamental question in this era of cost containment. The issue is one of determining which alcohol treatment modalities are the most effective for the least cost. The results of a meta-analysis of 33 treatment modalities suggested that brief interventions are the most cost-effective treatment and residential-milieu therapies are the least cost-effective (Holder et al., 1991). More recent research differs from these original findings in both cost and effectiveness determinations and points to the need to consider patient subgroups (Finney & Monahan, 1996). Nonetheless, both studies agreed that the more effective modalities consistently were in the medium-low to low cost range, and modalities with poor evidence were associated with higher costs. An important caveat to these findings is that none of the comparisons were done with individuals who were matched to treatment. It is likely that more expensive, intensive treatments may be necessary and cost-effective for more severe patients.

Cost-offset Cost-offset has as it fundamental objective cost savings and alone may not be a realistic social policy goal. Decisions not to fund more expensive treatments in an effort to contain costs may have important implications, because if the substance abuse problem worsens, the eventual result will be much higher costs (Fox et al., 1995). Estimates of the extent of alcohol-related hospital utilization are typically based on reviews of medical records and studies indicate that alcohol-related admissions have a significant impact on the cost of inpatient care (Gordis, 1987). In general, the cost-offset literature has focused on the health care costs following treatment and one study demonstrated 24% lower health-related costs for treated vs. untreated alcoholics over a 14 year follow-up period (Holder & Blose, 1992). Other researchers have found that treated alcoholics’ use of medical care decreased by 61% in the first year after treatment (Hoffman, De Hart & Fulkerson, 1993), absenteeism and medical claims were reduced (McDonnell Douglas Corporation, 1989) and arrests and incarcerations were decreased (Finigan, 1996). Holder (1998) summarized his review of the research on cost effectiveness with three major points: (1) untreated alcoholics use health care and incur costs at a rate about twice that of their non-alcoholic peers, (2) total health care utilization and costs begin to drop once treatment begins, and (3) there are no apparent gender differences in the utilization and associated costs before and after treatment initiation.

SUMMARY The past 40 years have brought with them a wealth of information about the treatment of alcohol problems. We have convincing evidence for the effectiveness of treatment and are

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at the frontier of developing new medications to reduce craving and relapse. Typically, in alcoholism treatment, lower cost treatments are at least as effective as more expensive ones and successful treatment is associated with lowered health care costs. Clearly, no one treatment will work for everyone. Perhaps encouraging professionals to adopt a comprehensive treatment program with a variety of approaches will allow more individuals to seek treatment. Encouraging individuals to understand that they have options and that they can be active participants in recovery represents a more sensitive approach to treatment.

KEY WORKS AND SUGGESTIONS FOR FURTHER READING Hester, R.K. & Miller, W.R. (1995). Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd edn. Needham Heights, MA: Allyn and Bacon. This handbook describes a variety of alternative treatment methods for helping those with alcohol problems. The book is written for practitioners and chapters have been contributed by some of the leading researchers in the field. Each clinical chapter includes an overview of the technique, special clinical considerations and guidelines for clinical applications. Miller, W.R. & Heather, N. (1998). Treating Addictive Behaviors, 2nd edn. New York: Plenum. Written from the perspective of the transtheoretical model of change, this edited book is a compilation of works by authors who base their writing on the latest research in the addictions field. Sections focus on understanding change, preparing for and facilitating change, and sustaining change in individuals who present with addictive behaviors. The book represents a collaboration between basic and applied research. Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change, 2nd edn. New York: Guilford. This volume is a must for clinicians working with individuals who are ambivalent about changing. This clearly written and immensely useful book outlines the steps to working with challenging clients. Motivational interviewing is detailed and practice exercises are included. Project MATCH Research Group (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH post-treatment drinking outcomes. Journal of Studies on Alcohol, 58, 7–29. This article represents an excellent overview of Project MATCH, including methodological details, research hypotheses, and directions for future research. The authors discuss the benefits of matching clients to treatment and provide a useful set of references for treatment delivery.

REFERENCES Azrin, N.H., Sisson, R.W., Meyers, R. & Godley, M. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Behavior Research and Therapy, 14, 339–348. Bien, T.H., Miller, W.R. & Tonigan, J.S. (1993). Brief interventions for alcohol problems: a review. Addiction, 88, 315–336.


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Bigelow, G.E. (2001). An operant behavioral perspective on alcohol abuse and dependence. In N. Heather, T.J. Peters & T. Stockwell (Eds), International Handbook of Alcohol Dependence and Problems (pp. 299–315). Chichester, UK: John Wiley & Sons. Bowman, K.M. & Jellinek, E.M. (1941). Alcohol addiction and its treatment. Quarterly Journal of Studies on Alcohol, 2, 98–176. Brower, K.J., Blow, F.C., Hill, E.M. & Mudd, S.A. (1994). Treatment outcome of alcoholics with and without cocaine disorders. Alcoholism: Clinical and Experimental Research, 18, 734–739. Brown, J.M. & Baumann, B.D. (1998). Recent advances in assessment and treatment of alcohol abuse and dependence. In L. Vandecreek, S. Knapp & T.L. Jackson (Eds), Innovations in Clinical Practice: A Sourcebook, Vol. 16 (pp. 81–93). Sarasota, FL: Professional Resources Press. Brown, T.G., Seraganian, P. & Tremblay, J. (1993). Alcohol and cocaine abusers 6 months after traditional treatment: do they fare as well as problem drinkers? Journal of Substance Abuse Treatment, 10, 545–552. Donovan, D.M. (1998). Continuing care: promoting the maintenance of change. In W.R. Miller & N. Heather (Eds), Treating Addictive Behaviors, 2nd edn (pp. 317–336). New York: Plenum. Drobes, D.J., Saladin, M.E. & Tiffany, S.T. (2001). Classical conditioning mechanisms in alcohol dependence. In N. Heather, T.J. Peters & T. Stockwell (Eds), International Handbook of Alcohol Dependence and Problems (pp. 281–297). Chichester, UK: John Wiley & Sons. Emrick, C.D. (1974). A review of psychologically oriented treatment of alcoholism: I. The use and interrelationships of outcome criteria and drinking behavior following treatment. Quarterly Journal of Studies on Alcohol, 35, 523–549. Finigan, M. (1996). Societal outcomes and cost savings of drug and alcohol treatment in the state of Oregon. Prepared for the Office of Alcohol and Drug Abuse Programs, Oregon Department of Human Resource, and Governor’s Council on Alcohol and Drug Abuse Programs, Salem, OR. Finney, J.W. & Monahan, S.C. (1996). The cost-effectiveness of treatment for alcoholism: a second approximation. Journal of Studies on Alcohol, 57, 229–243. Fox, K., Merrill, J.C., Chang, H.H. & Califano, J.A. Jr (1995). Estimating the costs of substance abuse to the Medicaid hospital care program. American Journal of Public Health, 85, 48–54. Gordis, E. (1987). Accessible and affordable health care for alcoholism and related problems: strategy for cost containment. Journal of Studies on Alcohol, 48, 579–585. Heather, N. (1998). Using brief opportunities for change in medical settings. In W.R. Miller & N. Heather (Eds), Treating Addictive Behaviors, 2nd edn (pp. 133–147). New York: Plenum. Hoffman, N.G., De Hart, S.S. & Fulkerson, J.A. (1993). Medical care utilization as a function of recovery status following chemical addictions treatment. Journal of Addictive Disease, 12, 97–108. Holder, H.D. (1998). Cost benefits of substance abuse treatment:An overview of results from alcohol and drug abuse. Journal of Mental Health Policy and Economics, 1, 23–29. Holder, H.D. & Blose, J.O. (1992). The reduction of health care costs associated with alcoholism treatment: a 14-year longitudinal study. Journal of Studies on Alcohol, 53, 293–302. Holder, H.D., Longabaugh, R., Miller, W.R. & Rubonis, A.V. (1991). The cost-effectiveness of treatment for alcoholism: a first approximation. Journal of Studies on Alcohol, 52, 517–540. Institute of Medicine (1989). Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: Institute of Medicine. Longabaugh, R., Rubin, A., Malloy, P., Beattie, M., Clifford, P.R. & Noel, N. (1994). Drinking outcomes of alcohol abusers diagnosed with antisocial personality disorder. Alcoholism: Clinical and Experimental Research, 18, 778–785. Mattson, M.E., Allen, J.P., Longabaugh, R., Nickless, C.J., Connors, G.J. & Kadden, R.M. (1994). A chronological review of empirical studies matching alcoholic clients to treatment. Journal of Studies on Alcohol, 12(Suppl.), 16–29. McCaul, M.E. & Furst, J. (1994). Alcoholism treatment in the United States. Alcohol Health and Research World, 18, 253–260. McCrady, B.S. & Langenbucher, J.W. (1996). Alcohol treatment and health care system reform. Archives of General Psychiatry, 53, 737–746. McDonnell Douglas Corporation & Alexander Consulting Group (1989). Employee assistance program financial offset study, 1985–1988. Washington DC: McDonnell Douglas Corporation. McKay, J.R. & Maisto, S.A. (1993). An overview and critique of advances in the treatment of alcohol use disorders. Drugs & Society, 8, 1–29.

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McKay, J.R., Maisto, S.A. & O’Farrell, T.J. (1993). End-of-treatment self-efficacy, aftercare and drinking outcomes of alcoholic men. Alcoholism: Clinical and Experimental Research, 17, 1078–1083. Miller, W.R., Andrews, N.R., Wilbourne, P. & Bennett, M.E. (1998). A wealth of alternatives: effective treatments for alcohol problems. In W.R. Miller & N. Heather (Eds), Treating Addictive Behaviors, 2nd edn (pp. 203–216). New York: Plenum. Miller, W.R., Benefield, R.G. & Tonigan, J.S. (1993). Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455–461. Miller, W.R., Brown, J.M., Simpson, T.L., Handmaker, N.S., Bien, T.H., Luckie, L.F., Montgomery, H.A., Hester, R.K. & Tonigan, J.S. (1995). What works? A methodological analysis of the alcohol treatment outcome literature. In R.K. Hester & W.R. Miller (Eds), Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd edn (pp. 12–44). Needham Heights, MA: Allyn and Bacon. Miller, W.R. & Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford. Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd edn). New York: Guilford. Monti, P.M., Rohsenow, D.J., Colby, S.M. & Abrams, D.B. (1995). Coping and social skills training. In R.K. Hester & W.R. Miller (Eds), Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd edn (pp. 221–241). Needham Heights, MA: Allyn and Bacon. Moos, R.H., Finney, J.W. & Cronkite, R.C. (1990). Alcoholism Treatment: Context, Process, and Outcome. New York: Oxford University Press. Najavits, L.M. & Weiss, R.D. (1994). Variations in therapist effectiveness in the treatment of patients with substance use disorders: an empirical review. Addiction, 89, 679–688. O’Malley, S.S., Jaffe, A.J., Chang, G., Schottenfeld, R.S., Meyer, R.E. & Roundsaville, B. (1992). Naltrexone and coping skills therapy for alcohol dependence: a controlled study. Archives of General Psychiatry, 49, 881–887. Powell, B.J., Campbell, J.L., Landon, J.F., Liskow, B.I., Thomas, H.M., Nickel, E.J., Dale, T.M., Penick, E.C., Samuelson, S.D. & Lacoursiere, R.B. (1995). A double-blind, placebo-controlled study of nortriptyline and bromocriptine in male alcoholics subtyped by comorbid psychiatric disorders. Alcoholism: Clinical and Experimental Research, 19, 462–468. Project MATCH Research Group (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58, 7–29. Rychtarik, R.G., Prue, D.M., Rapp, S.R. & King, A.C. (1992). Self-efficacy, aftercare and relapse in a treatment program for alcoholic. Journal of Studies on Alcohol, 53, 435– 440. Weingardt, K.R. & Marlatt, G.A. (1998). Sustaining change: helping those who are still using. In W.R. Miller & N. Heather (Eds), Treating Addictive Behaviors, 2nd edn (pp. 337–351). New York: Plenum. Weinrieb, R.M. & O’Brien, C.P. (1997). Naltrexone in the treatment of alcoholism. Annual Review in Medicine, 48, 477–487.