Percepirral and Motor Skills, 1975,41, 695-700. @ Perceptual and Motor Skills 1975
ISSUES I N TREATMENT EFFICACY RESEARCH WITH ALCOHOLICS1 GERALDINE K. PIORKOWSKIQND
EDWARD
T. MANN
College o f Medicine and Dentistry of N e w Jersey N e w Jersey Medical School Summary.-A variery of therapeutic strategies have been used in the treatment of alcoholic patients. Within this context, behavioral techniques have been widely employed with varying degree of effectiveness. This paper attempts to explore theoretically 2 widely used behavioral therapeutic methods, systematic desensitization and covert sensitizacion, along with traditional insight-oriented therapy. Possible merits and limirations of applying these treatment approaches ro alcoholic patienrs are explored.
In the course of an investigation designed to assess the treatment efficacy of three approaches to alcoholism, significant theoretical and practical problems with the therapeutic approaches as well as the research strategy became apparent. Because such problems need to be considered in future comparative studies of treatment efficacy, this paper focuses on the issues involved in utilizing systematic desensitization ( Wolpe, 1969), covert sensitizacion ( Cautela, 1967, 1970), and insight therapy with alcoholics. For the purpose of providing a context for discussion, a brief summary of the study itself follows. This research was designed to compare the efficacy of two techniques, systematic desensitization and insight therapy, which focus on variables assumed to be antecedent to excessive drinking - with a technique which focuses directly on the drinking response (covert sensitizacion). Outpatient alcoholic Ss, who possessed at least a 6th grade reading level and who were without psychotic and/or organic symptoms, were assigned randomly to one of three treatment conditions and to one of two therapists (the authors) who administered all three types of treatment. Each S was told that in order to be continued in the program, abstinence for 24 hr. prior to each therapeutic contact was important. This criterion was designed to reduce the likelihood of Ss attending sessions in an intoxicated state. The authors believed that very little learning would occur while a person is intoxicated.
METHODAND RESULTS Ss were seen individually for 14 sessions of 30 to 45 min. in length and follow-ups were completed in monthly interviews for a period of 6 mo. after 'A preliminary version of this paper was presented at the Fifrh Annual Meeting of the Association for Advancement of Behavior Therapy, Washington. D.C..September. 1971. w o w at Illinois State Psychiatric Institure. chicago, Illinois. - ~ e ~ u e s 'for t s ;eprints'shbuld be sent to Geraldine K. Piorkowski, Ph.D., Illinois State Psychiatric Institute, 1601 W. Taylor Street, Chicago, Illinois 60612.
696
G. K. PIORKOWSKI ~r E. T. MANN
termination. I n the systematic desensitization condicion, those anxieties which, on the basis of a questionnaire and the Fear Survey Schedule (Wolpe & Lang, 1964), were viewed as underlying the maladaptive drinking response were selected for desensicizarion. The covert sensitization condition essentially followed the Ashem and Donner procedure (Ashem & Donner, 1968). In the insight therapy condition, the focus was on clarifying feelings and motives which enter the excessive drinking and to effect positive changes in S's attitudes about himself and negative changes in his attitude about alcohol. Of the 37 males and 3 females who entered the research program, only 13 male Ss and 1 female S completed [he 14 sessions. Of the remaining 26 Ss, 3 were referred to an inpatient setting because of continued heavy drinking while 23 dropped out for a variety of reasons. On the basis of the initial personality testing, the alcoholic males who began the program were highly neurotic, introverted, anxious, and internally oriented on Rorter's I-E scale (Rotrer, 1966).3 At the time of termination, 10 of the 14 Ss who completed the treatment program had been abstinent from alcohol for at least a month, according to 3s' self-reports. However, at the time of the 6th month follow-up, only 3 Ss reported being totally abstinent from alcohol throughout the post-termination period. There was no evidence of specific treatment effecrs as each of the 3 abstinent Ss was in a different treatment condicion. There was, however, evidence suggestive of a significant therapist effect as all 3 of the totally abstinent Ss were treated by the same therapist. Because of the small N in each rreatment condition and the use of retrospective self-reports of drinking behavior, the results themselves are inconclusive. However, the reports of Ss and the observations of the authors throughout the study highlight both the advantages and the limitations of these 3 techniques.
DISCUSSION On the basis of Ss' reports and the authors' observations, covert sensitization appeared to be the least effective of the three techniques. None of the Ss who completed the covert sensitization procedure nor those who prematurely terminated reported any emotional reaction other than a very mild conditioned aversion to alcohol. This mild aversion appeared to be readily overcome if S continued to drink past the point of nausea. Two Ss reported this phenomenon. Both Ss tended to regard the nausea as an externally imposed obstacle which could be overcome with persistent drinking. However, another S who also seemed to consider the nausea as externally imposed challenged the technique by entering a bar. H e sac at the stool and stated that, "as soon as I sat down my 'On the Maudsley Personaliry Inventory, the mean for the entire male sample ( N = 3 7 ) on the extraversion scale was 23.52, SD = 9.25, while the mean on the neuroticism scale was 33.22, SD = 9.7. On the IPAT, the total anxiery score was 44.5, SD = 5.5, while the I-E scale mean was 6.9, SD = 4.00.
ISSUES IN TREATMENT OF ALCOHOLICS
697
desire for a drink ceased." Nausea was not felt to be the cause of his disinterest. H e ordered coffee and left, feeling that he was the victor and now possessing complete control of his impulses. From this point on, his fear of rerurning to alcohol appreciably diminished. Several other Ss in covert sensitization reported that the avetsive imagery was similar to their own experience prior to treatment, experiences which did not deter them from drinking. They would feel nauseous immediately prior to and following the ingestion of alcohol. However, shortly after vomiting, they were able to resume drinking without any immediate discomfort. One S, who succeeded in overcoming the mild aversive reaction, reported with conviction "you can't scare an alcoholic." It is quite possible that for those Ss who did not benefit from covert sensitization, the procedure raised their anxiety level, thereby increasing their need to imbibe alcohol to effect anxiety reduction. There are several other problems in both the theory and practice of covert sensitization. The intensity of the aversive stimulus, that is, the affect-laden impact of the scene, appears to be primarily under the cognitive control of S and is difficult for the therapist to control. After a covert sensitization session, one S admitted that he did not like to think about the unpleasant effects of alcohol so he would think about his girlfriend whenever rhe therapist began describing the aversive sensations. It was not clear whether his girlfriend became more aversive or alcohol more positive for him. It appears that considerable time must be given to continual monitoring of S's imagery and the details of the scenes depicted. Any S who is so highly motivated as to experience intensely and repeatedly all the negative emotions connected with aversive imagery can probably stop drinking in a less traumatic manner. Another problem with covert sensitization concerns the issue of adaptation. Covert sensitization had an emotional impact upon S during the first several presentations. However, after repeated exposure, adaptation to the aversive presentation occurred in spite of the therapist's attempts to vary the aversive scenes, a procedure suggested by Cautela (1970). It seems reasonable to assume that an externally imposed aversive image will lose some of its potency to evoke negative feelings after it has been visualized 20 times or more. It became apparent early in the treatment process with two Ss in the covert sensitization condition that overconfidence in their ability to succeed was having an inhibitory effect on their progress. Such an attitude was evident when one S commented, "All I needed was the right direction and now that I have it, I'm all set." Needless to say, Ss began missing scheduled appointments until they began drinking. At that point, they telephoned the therapist requesting another appointment. Several investigators have agreed that other behavioral techniques be utilized in conjunction with covert sensitization in the total treatment of alcoholism.
698
G.K. PIORKOWSKI
8~
E. T. MANN
Cautela (1970) advocates the use of systematic desensitization and assertive training along with covert sensitization while Bandura (1969) supports modeling and reinforcement procedures. However, it is important to establish what is the unique contribution of covert sensitization to the treatment process. From the authors' experience, covert sensitization appeared to have some value in reducing alcohol intake early in the treatment process. Whether this is a function of a mild aversive reaction, suggestion or the magical aura of a "scientific" technique is not clear as yet. In contrast to covert sensitization, sysrematic desensitization was generally regarded as beneficial by these Ss. All Ss who completed systematic desensitization reported a general reduction in tension along with specific fear reduction to hierarchy items. While reported reduction in tension was accompanied in most instances by reduced alcohol intake, it appeared that for some Ss, the drinking response was not related to anxiety but was elicited by situational cues and maintained by non-anxiety-related contingencies, such as increased assertiveness or heigh tened feelings of comraderie. One of the major problems with systematic desensitization in this study was the identification of chose anxieties which have a dynamic or temporal relationship to the drinking response. Those tensions seen as antecedents to the drinking behavior were easier to identify in periodic or binge drinkers than in daily drinkers. With daily drinkers, the tensions which may have been significant in the initiation of the problematic drinking behavior were not always apparent after several years of daily drinking. With this group, the stimulus antecedents of the drinking behavior tended to be external cues (passing a bar, a specified time of day, etc.) rather than a specific feeling or tension. With these Ss, tensions were selected for desensitization which appeared to have the most debilitating effect upon S's life. For one S who was a daily drinker, anxieties about riding a bus and tension in job interviews were desensitized successfully with corresponding reduction in alcohol intake. With several other Ss who were assigned to the sysrematic desensitization condition but did not complete the 14 sessions, hierarchy construction represented a significant problem. These Ss were generally non-verbal and seemed unable to conceptualize and identify the situational factors which usually underlie the maladaptive approach behavior. With these Ss, the Fear Survey Schedule provided little assistance in hierarchy construction. As a result, fastidious attention to compiling hierarchies for Ss characterized as socially deprived and educationally deficient, with marginal intellectual and affective awareness, proved to be discouraging. Two other Ss in systematic desensitization presented rather complicated features which were viewed as habituated and resistant to change. The first S could not conform to the research requirement of being abstinent for 24 hr. prior
ISSUES IN TREATMENT OF ALCOHOLICS
699
to each treatment session. As the desensitizacion process continued, he slowly began to "wean" himself away from alcohol. By the 13th session, he had been able to inhibit intake completely, During this transition, positive social changes resulting directly from the systematic desensitizacion were observed. Another S for whom several desensitization hierarchies were developed remained abstinent throughout treatment but became highly anxious midway through the program. At that time, he stated thac one persistent source of anxiety (fear of eye contact with others) seen initially by S as rather insignificant, was now so incapacitating as to endanger effectiveness of treatment. This fear presented a unique problem for traditional desensitizacion procedures. As a result, a modification of the rehearsal-desensitization method (Piaget & Lazarus, 1969) was used. This approach was effective in reducing the maladaptive behavior and restored his ability to complete Treatment successfully. Another problem wich systematic desensitization was the 14-session limitation. With two of the Ss, relaxation training accounted for over two-thirds of the time allotted to treatment because of Ss' difficulties in relaxation. One of these Ss had marked anxiety about relaxation training per Je (he was fearful about being hypnotized) and also was anxious about doctors, female doctors especially (his therapist was the female author). Relaxation training tended to constitute 7,n vivo desensitization for him. Whenever the time limitation interfered with adequate desensitization of at least one hierarchy, S was dropped from the research design and continued in desensitization as long as necessary. In insight therapy, the absence of structure was both its greatest asset (in thac there is more flexibility as to technique within this condition) and yet, its greatest liability. The absence of structure appeared to result in a dropout rate higher than in the other two conditions. Insight therapy, as all clinicians realize, is not a unitary condition. It tends to be a potpourri of many techniques, such as reassurance, positive reinforcement, clarification of feelings, and confrontation within the context of an interpersonal relationship. As such, an insight therapy condition can only be regarded as a control group for non-specific treatment effects. That there are non-specific treatment effects was evident in this study not only from the comparable treatment effects across conditions but from the initial period of abstinence (time lapse between first contact wich the program and first drink) which the majority of Ss manifested. Of the 27 Ss on whom information was available, 2 1 Ss had an initial period of abstinence of at least one week with 11 of these Ss abstinent for at least one month. These non-specific treatment effects were felt to be related primarily to variables in the relationship between Sand the therapist and also to the high initial motivation of S. During this time period when 5"s motivation is high, therapeutic efforts should be concentrated upon enhancing the positive effects of sobriety.
700
G. K. PIORKOWSKI
&
E. T. MANN
In general, the over-all design of this study is one which can be implemented in any outpatient setting. The design is open, that is, new treatment conditions can be added and evaluated at any time. In this study, the random assignment of Ss to treatment conditions resulted in a few apparent "mismatches." Nonverbal Ss being assigned to insight therapy or non-anxious Ss to systematic desensitization were among the obvious instances of mismatching. However, the major difficulty which arose in this investigation was the high percentage of SS who dropped out of treatment before completing the 14 sessions. One explanation for this high drop-out rate may be the fact that the majority of SS who volunteered for treatment came to the clinic because of an alcohol-related physical problem which required medical treatment. (The primary funcrion of the outpatient clinic, which was located in a large metropolitan hospital, was to provide medical treatment for alcoholics.) Once the physical problem was resolved or the acute medical phase had subsided, the motivation for psychological treatment appeared to diminish significantly. For this subgroup of alcoholics, that is, the alcoholics whose drinking has begun to create physical problems, unique incentives may be required to keep these Ss in treatment. Another issue specific to this study, namely, the requirement of 24 hr. abstinence prior to each session, may be contributed to the high drop-out rate. As indicated earlier, the purpose of this requirement was to ensure that reasonably intact Ss appeared for sessions. This requirement, however, may have been aversive in that it served to keep Ss who had some exposure to alcohol prior to each session away from treatment. Flexibility as to degree of abstinence expected during the treatment phase should be investigated in any future study. Another modification which would increase the reliability of self-reporting in treatment is to include ongoing detailed weekly reports of drinking behavior. Ultimately, the goal of comparative treatment efficacy research is to be able to assign Ss to treatment conditions on the basis of the predicted superiority of that treatment for that particular S. At this stage of our knowledge, that goal is a distant one. REFERENCES ASHEM, B., & DONNER,L. Covert sensitization with alcoholics: a controlled replication. Behavior Resea~chand Therapy, 1968. 6 , 7-12. BANDURA, A. Principles o f behavior modificatio7i. New York: Holr, 1969. CAUTELA,J. Covert sensitization. Psychological Reports, 1967, 20, 459-468. CAUTELA,J. The treaunent of alcoholism by covert sensitization. Psychotherapy: Theory, Research, and Practice, 1970. 7 , 86-90. PIAGET, G. W., & LAZARUS,A. A. The use of rehearsal desensitization. Psychotherapy: Theory, Research and Practice, 1969, 6 , 264-266. R o ~ R J., Generalized expectancies for internal versus external control of reinforce. ment. Psychological Monographs, 1966, 80, No. 1 (Whole No. 6 0 9 ) . WOLPE,J. T h e Practice o f behavior therapy. New York: Pergarnon, 1969. WOLPE.J., & LANG,P. A fear survey schedule for use in behavior therapy. Behavior Research and Therapy, 1964, 2, 27-30. Accepted August 22, 1975.
ISSUES I N TREATMENT EFFICACY RESEARCH WITH ALCOHOLICS1 GERALDINE K. PIORKOWSKIQND
EDWARD
T. MANN
College o f Medicine and Dentistry of N e w Jersey N e w Jersey Medical School Summary.-A variery of therapeutic strategies have been used in the treatment of alcoholic patients. Within this context, behavioral techniques have been widely employed with varying degree of effectiveness. This paper attempts to explore theoretically 2 widely used behavioral therapeutic methods, systematic desensitization and covert sensitizacion, along with traditional insight-oriented therapy. Possible merits and limirations of applying these treatment approaches ro alcoholic patienrs are explored.
In the course of an investigation designed to assess the treatment efficacy of three approaches to alcoholism, significant theoretical and practical problems with the therapeutic approaches as well as the research strategy became apparent. Because such problems need to be considered in future comparative studies of treatment efficacy, this paper focuses on the issues involved in utilizing systematic desensitization ( Wolpe, 1969), covert sensitizacion ( Cautela, 1967, 1970), and insight therapy with alcoholics. For the purpose of providing a context for discussion, a brief summary of the study itself follows. This research was designed to compare the efficacy of two techniques, systematic desensitization and insight therapy, which focus on variables assumed to be antecedent to excessive drinking - with a technique which focuses directly on the drinking response (covert sensitizacion). Outpatient alcoholic Ss, who possessed at least a 6th grade reading level and who were without psychotic and/or organic symptoms, were assigned randomly to one of three treatment conditions and to one of two therapists (the authors) who administered all three types of treatment. Each S was told that in order to be continued in the program, abstinence for 24 hr. prior to each therapeutic contact was important. This criterion was designed to reduce the likelihood of Ss attending sessions in an intoxicated state. The authors believed that very little learning would occur while a person is intoxicated.
METHODAND RESULTS Ss were seen individually for 14 sessions of 30 to 45 min. in length and follow-ups were completed in monthly interviews for a period of 6 mo. after 'A preliminary version of this paper was presented at the Fifrh Annual Meeting of the Association for Advancement of Behavior Therapy, Washington. D.C..September. 1971. w o w at Illinois State Psychiatric Institure. chicago, Illinois. - ~ e ~ u e s 'for t s ;eprints'shbuld be sent to Geraldine K. Piorkowski, Ph.D., Illinois State Psychiatric Institute, 1601 W. Taylor Street, Chicago, Illinois 60612.
696
G. K. PIORKOWSKI ~r E. T. MANN
termination. I n the systematic desensitization condicion, those anxieties which, on the basis of a questionnaire and the Fear Survey Schedule (Wolpe & Lang, 1964), were viewed as underlying the maladaptive drinking response were selected for desensicizarion. The covert sensitization condition essentially followed the Ashem and Donner procedure (Ashem & Donner, 1968). In the insight therapy condition, the focus was on clarifying feelings and motives which enter the excessive drinking and to effect positive changes in S's attitudes about himself and negative changes in his attitude about alcohol. Of the 37 males and 3 females who entered the research program, only 13 male Ss and 1 female S completed [he 14 sessions. Of the remaining 26 Ss, 3 were referred to an inpatient setting because of continued heavy drinking while 23 dropped out for a variety of reasons. On the basis of the initial personality testing, the alcoholic males who began the program were highly neurotic, introverted, anxious, and internally oriented on Rorter's I-E scale (Rotrer, 1966).3 At the time of termination, 10 of the 14 Ss who completed the treatment program had been abstinent from alcohol for at least a month, according to 3s' self-reports. However, at the time of the 6th month follow-up, only 3 Ss reported being totally abstinent from alcohol throughout the post-termination period. There was no evidence of specific treatment effecrs as each of the 3 abstinent Ss was in a different treatment condicion. There was, however, evidence suggestive of a significant therapist effect as all 3 of the totally abstinent Ss were treated by the same therapist. Because of the small N in each rreatment condition and the use of retrospective self-reports of drinking behavior, the results themselves are inconclusive. However, the reports of Ss and the observations of the authors throughout the study highlight both the advantages and the limitations of these 3 techniques.
DISCUSSION On the basis of Ss' reports and the authors' observations, covert sensitization appeared to be the least effective of the three techniques. None of the Ss who completed the covert sensitization procedure nor those who prematurely terminated reported any emotional reaction other than a very mild conditioned aversion to alcohol. This mild aversion appeared to be readily overcome if S continued to drink past the point of nausea. Two Ss reported this phenomenon. Both Ss tended to regard the nausea as an externally imposed obstacle which could be overcome with persistent drinking. However, another S who also seemed to consider the nausea as externally imposed challenged the technique by entering a bar. H e sac at the stool and stated that, "as soon as I sat down my 'On the Maudsley Personaliry Inventory, the mean for the entire male sample ( N = 3 7 ) on the extraversion scale was 23.52, SD = 9.25, while the mean on the neuroticism scale was 33.22, SD = 9.7. On the IPAT, the total anxiery score was 44.5, SD = 5.5, while the I-E scale mean was 6.9, SD = 4.00.
ISSUES IN TREATMENT OF ALCOHOLICS
697
desire for a drink ceased." Nausea was not felt to be the cause of his disinterest. H e ordered coffee and left, feeling that he was the victor and now possessing complete control of his impulses. From this point on, his fear of rerurning to alcohol appreciably diminished. Several other Ss in covert sensitization reported that the avetsive imagery was similar to their own experience prior to treatment, experiences which did not deter them from drinking. They would feel nauseous immediately prior to and following the ingestion of alcohol. However, shortly after vomiting, they were able to resume drinking without any immediate discomfort. One S, who succeeded in overcoming the mild aversive reaction, reported with conviction "you can't scare an alcoholic." It is quite possible that for those Ss who did not benefit from covert sensitization, the procedure raised their anxiety level, thereby increasing their need to imbibe alcohol to effect anxiety reduction. There are several other problems in both the theory and practice of covert sensitization. The intensity of the aversive stimulus, that is, the affect-laden impact of the scene, appears to be primarily under the cognitive control of S and is difficult for the therapist to control. After a covert sensitization session, one S admitted that he did not like to think about the unpleasant effects of alcohol so he would think about his girlfriend whenever rhe therapist began describing the aversive sensations. It was not clear whether his girlfriend became more aversive or alcohol more positive for him. It appears that considerable time must be given to continual monitoring of S's imagery and the details of the scenes depicted. Any S who is so highly motivated as to experience intensely and repeatedly all the negative emotions connected with aversive imagery can probably stop drinking in a less traumatic manner. Another problem with covert sensitization concerns the issue of adaptation. Covert sensitization had an emotional impact upon S during the first several presentations. However, after repeated exposure, adaptation to the aversive presentation occurred in spite of the therapist's attempts to vary the aversive scenes, a procedure suggested by Cautela (1970). It seems reasonable to assume that an externally imposed aversive image will lose some of its potency to evoke negative feelings after it has been visualized 20 times or more. It became apparent early in the treatment process with two Ss in the covert sensitization condition that overconfidence in their ability to succeed was having an inhibitory effect on their progress. Such an attitude was evident when one S commented, "All I needed was the right direction and now that I have it, I'm all set." Needless to say, Ss began missing scheduled appointments until they began drinking. At that point, they telephoned the therapist requesting another appointment. Several investigators have agreed that other behavioral techniques be utilized in conjunction with covert sensitization in the total treatment of alcoholism.
698
G.K. PIORKOWSKI
8~
E. T. MANN
Cautela (1970) advocates the use of systematic desensitization and assertive training along with covert sensitization while Bandura (1969) supports modeling and reinforcement procedures. However, it is important to establish what is the unique contribution of covert sensitization to the treatment process. From the authors' experience, covert sensitization appeared to have some value in reducing alcohol intake early in the treatment process. Whether this is a function of a mild aversive reaction, suggestion or the magical aura of a "scientific" technique is not clear as yet. In contrast to covert sensitization, sysrematic desensitization was generally regarded as beneficial by these Ss. All Ss who completed systematic desensitization reported a general reduction in tension along with specific fear reduction to hierarchy items. While reported reduction in tension was accompanied in most instances by reduced alcohol intake, it appeared that for some Ss, the drinking response was not related to anxiety but was elicited by situational cues and maintained by non-anxiety-related contingencies, such as increased assertiveness or heigh tened feelings of comraderie. One of the major problems with systematic desensitization in this study was the identification of chose anxieties which have a dynamic or temporal relationship to the drinking response. Those tensions seen as antecedents to the drinking behavior were easier to identify in periodic or binge drinkers than in daily drinkers. With daily drinkers, the tensions which may have been significant in the initiation of the problematic drinking behavior were not always apparent after several years of daily drinking. With this group, the stimulus antecedents of the drinking behavior tended to be external cues (passing a bar, a specified time of day, etc.) rather than a specific feeling or tension. With these Ss, tensions were selected for desensitization which appeared to have the most debilitating effect upon S's life. For one S who was a daily drinker, anxieties about riding a bus and tension in job interviews were desensitized successfully with corresponding reduction in alcohol intake. With several other Ss who were assigned to the sysrematic desensitization condition but did not complete the 14 sessions, hierarchy construction represented a significant problem. These Ss were generally non-verbal and seemed unable to conceptualize and identify the situational factors which usually underlie the maladaptive approach behavior. With these Ss, the Fear Survey Schedule provided little assistance in hierarchy construction. As a result, fastidious attention to compiling hierarchies for Ss characterized as socially deprived and educationally deficient, with marginal intellectual and affective awareness, proved to be discouraging. Two other Ss in systematic desensitization presented rather complicated features which were viewed as habituated and resistant to change. The first S could not conform to the research requirement of being abstinent for 24 hr. prior
ISSUES IN TREATMENT OF ALCOHOLICS
699
to each treatment session. As the desensitizacion process continued, he slowly began to "wean" himself away from alcohol. By the 13th session, he had been able to inhibit intake completely, During this transition, positive social changes resulting directly from the systematic desensitizacion were observed. Another S for whom several desensitization hierarchies were developed remained abstinent throughout treatment but became highly anxious midway through the program. At that time, he stated thac one persistent source of anxiety (fear of eye contact with others) seen initially by S as rather insignificant, was now so incapacitating as to endanger effectiveness of treatment. This fear presented a unique problem for traditional desensitizacion procedures. As a result, a modification of the rehearsal-desensitization method (Piaget & Lazarus, 1969) was used. This approach was effective in reducing the maladaptive behavior and restored his ability to complete Treatment successfully. Another problem wich systematic desensitization was the 14-session limitation. With two of the Ss, relaxation training accounted for over two-thirds of the time allotted to treatment because of Ss' difficulties in relaxation. One of these Ss had marked anxiety about relaxation training per Je (he was fearful about being hypnotized) and also was anxious about doctors, female doctors especially (his therapist was the female author). Relaxation training tended to constitute 7,n vivo desensitization for him. Whenever the time limitation interfered with adequate desensitization of at least one hierarchy, S was dropped from the research design and continued in desensitization as long as necessary. In insight therapy, the absence of structure was both its greatest asset (in thac there is more flexibility as to technique within this condition) and yet, its greatest liability. The absence of structure appeared to result in a dropout rate higher than in the other two conditions. Insight therapy, as all clinicians realize, is not a unitary condition. It tends to be a potpourri of many techniques, such as reassurance, positive reinforcement, clarification of feelings, and confrontation within the context of an interpersonal relationship. As such, an insight therapy condition can only be regarded as a control group for non-specific treatment effects. That there are non-specific treatment effects was evident in this study not only from the comparable treatment effects across conditions but from the initial period of abstinence (time lapse between first contact wich the program and first drink) which the majority of Ss manifested. Of the 27 Ss on whom information was available, 2 1 Ss had an initial period of abstinence of at least one week with 11 of these Ss abstinent for at least one month. These non-specific treatment effects were felt to be related primarily to variables in the relationship between Sand the therapist and also to the high initial motivation of S. During this time period when 5"s motivation is high, therapeutic efforts should be concentrated upon enhancing the positive effects of sobriety.
700
G. K. PIORKOWSKI
&
E. T. MANN
In general, the over-all design of this study is one which can be implemented in any outpatient setting. The design is open, that is, new treatment conditions can be added and evaluated at any time. In this study, the random assignment of Ss to treatment conditions resulted in a few apparent "mismatches." Nonverbal Ss being assigned to insight therapy or non-anxious Ss to systematic desensitization were among the obvious instances of mismatching. However, the major difficulty which arose in this investigation was the high percentage of SS who dropped out of treatment before completing the 14 sessions. One explanation for this high drop-out rate may be the fact that the majority of SS who volunteered for treatment came to the clinic because of an alcohol-related physical problem which required medical treatment. (The primary funcrion of the outpatient clinic, which was located in a large metropolitan hospital, was to provide medical treatment for alcoholics.) Once the physical problem was resolved or the acute medical phase had subsided, the motivation for psychological treatment appeared to diminish significantly. For this subgroup of alcoholics, that is, the alcoholics whose drinking has begun to create physical problems, unique incentives may be required to keep these Ss in treatment. Another issue specific to this study, namely, the requirement of 24 hr. abstinence prior to each session, may be contributed to the high drop-out rate. As indicated earlier, the purpose of this requirement was to ensure that reasonably intact Ss appeared for sessions. This requirement, however, may have been aversive in that it served to keep Ss who had some exposure to alcohol prior to each session away from treatment. Flexibility as to degree of abstinence expected during the treatment phase should be investigated in any future study. Another modification which would increase the reliability of self-reporting in treatment is to include ongoing detailed weekly reports of drinking behavior. Ultimately, the goal of comparative treatment efficacy research is to be able to assign Ss to treatment conditions on the basis of the predicted superiority of that treatment for that particular S. At this stage of our knowledge, that goal is a distant one. REFERENCES ASHEM, B., & DONNER,L. Covert sensitization with alcoholics: a controlled replication. Behavior Resea~chand Therapy, 1968. 6 , 7-12. BANDURA, A. Principles o f behavior modificatio7i. New York: Holr, 1969. CAUTELA,J. Covert sensitization. Psychological Reports, 1967, 20, 459-468. CAUTELA,J. The treaunent of alcoholism by covert sensitization. Psychotherapy: Theory, Research, and Practice, 1970. 7 , 86-90. PIAGET, G. W., & LAZARUS,A. A. The use of rehearsal desensitization. Psychotherapy: Theory, Research and Practice, 1969, 6 , 264-266. R o ~ R J., Generalized expectancies for internal versus external control of reinforce. ment. Psychological Monographs, 1966, 80, No. 1 (Whole No. 6 0 9 ) . WOLPE,J. T h e Practice o f behavior therapy. New York: Pergarnon, 1969. WOLPE.J., & LANG,P. A fear survey schedule for use in behavior therapy. Behavior Research and Therapy, 1964, 2, 27-30. Accepted August 22, 1975.
