Drug and Alcohol Dependence, 1 (1975/76) @ Elsevler Sequoia S.A., Lausanne - Printed
241 - 246 in the Netherlands
TREATMENT EFFECTIVENESS AS JUDGED BY SUCCESSFULLY AND IJNSUCCESSFULLY TREATED ALCOHOLICS
H. HOFFMANN,
A. A. NOEM
Willmar (MN) State (Received
Hospital,
and D. PETERSEN Willmar,
Minnesota
56201
(U.S.A.)
June 23, 1975)
Summary Thirty-seven successfully and 46 unsuccessfully treated male alcoholics were asked to judge the effectiveness or ineffectiveness of six treatment methods routinely offered by a state hospital. For each treatment method, the total frequencies of judgments of most and least helpful, respectively, were as follows: detoxification (16%, 14X), lectures (16/z , 20X), group therapy (54%, 7%), individual counseling (26%, 6%), work therapy (1770, 22%) and family therapy (13%, 14,Z). The two groups of subjects differed significantly in the frequencies of treatment methods judged to be “least helpful”, but not in the frequencies of “most helpful” treatment. The similarity between the judgments of successfully and unsuccessfully treated alcoholics might reflect the positive effects of previous treatment in the unsuccessful group.
A common method of evaluating the effectiveness of different treatment methods consists of the random assignment of subjects to two or more treatment groups and the measurement of treatment outcome, usually in terms of abstinence, by follow-up methods [l - 31. An alternative approach to treatment evaluation would be to take the patient’s feelings toward the treatment process and its effectiveness into consideration. The principle of patient feedback was considered by Fitzgibbons, Cutler and Cohen [4] in their investigation of psychiatric patients’ self-perceived treatment needs and by Jansen [ 51 in his investigation of psychiatric patients’ treatment preferences. However, such a systematic investigation of alcoholics’ conceptions of the effects of various treatment methods has not been fully implemented in treatment evaluation. The present study investigated whether or not there were differences (a) among patients’ judgments of effectiveness of routinely offered alcohol. treatment methods, and (b) between the effectiveness of various alcohol treatment methods as judged by successfully treated alcoholics and as judged by unsuccessfully treated alcoholics.
241
242
Method The subjects consisted of two groups of male alcoholics. Group I was comprised of 37 alcoholics who had formerly received treatment at Willmar State Hospital and returned there to attend an Annual Chemical Dependency Alumni Meeting. Considering that these subjects (a) attended an annual alumni meeting, (b) had a mean period of 5.3 years since their last treatment and (c) claimed sobriety, it appears reasonable to label this group a successfully treated one. Group II consisted of 46 male alcoholics who also had received treatment at Willmar State Hospital and were readmitted into treatment there on account of a relapse in drinking. These subjects were labeled a treatment failure group because of their return to drinking after treatment and subsequent readmission into treatmen The drinking patterns of the groups classified as successful and failure showed obvious differences. Relapses to drinking at any time after discharge were reported for 27% of the success group and 100% of the failure group (x2 = 53.13, df = 1, p < 0.001). One month after discharge, such relapses occurred in 10.8% of the success group and 26.1% of the failure group (x 2 = 4 . 14, df = 1, p < 0.05). At three months after discharge, 18.9% of the success group and 60.9% of the failure group (x2 = 16.57, df = 1, p < 0.001) experienced a relapse. The longest period of sobriety being more than one year was 81.1% for the success group and 6.5% for the failure group (x 2 = 50.84, df = 1, p < 0.001). With respect to the current drinking pattern, 94.6% of the success group and not one percent of the failure group reported total abstinence (x2 = 79.17, df = 1, p < 0.001). There were no significant age differences between the two groups (M, = 44.62 yr., M, = 44.76 yr., t = 0.06). However, the groups did differ significantly on the variables of years of education (M, = 11.84 yr., M2 = 9.52 yr., t = -4.77, p < 0.001) and number of married subjects (Group I = 73%, Group II = 41%, x2 = 8.30, df = 1, p < 0.01). The treatment offered by the alcoholism treatment unit was a six week, AA oriented treatment. The major treatment methods routinely offered by the treatment center were: detoxification, lectures on alcoholism and alcohol associated problems, group therapy, individual counseling conducted by counselors on alcoholism and psychologists, work therapy and family counseling. Each subject was asked to indicate on a specially composed questionnaire which of the major aspects of treatment they judged “most helpful” and which “least helpful”. All patients received all types of treatment. The test-retest reliability of individual treatment items within one week testing interval were: detoxification 0.63, lectures 0.47, group therapy 0.40, individual counseling 0.47, work therapy 0.54 and family therapy 0.47. For df = 54, all were significant at the 0.01 level of confidence or better. Subjects had the opportunity to indicate more than one treatment method as being most or least helpful. Chi-square analysis and Fisher’s Exact Method were used for the statistical analysis, as appropriate.
243
TABLE
1
CJudgments of successfully (Group I) and unsuccessfully (Group of the effectiveness of treatment methods (in percentage)“* Effectiveness
Most helpful
Least
helpful
Group N = (Subjects) No. of responses
I 37 58
II 46 60
Total 83 118
I 37 36
II 46 34
Detoxification Lectures Group therapy Individual counseling Work therapy Family therapy
14 16 59 38 8 22
17 15 50 17 24 7
16 16 54 26 17 13
14 24 0 8 43 8
15 17 13 4 4 20
‘Because of multiple responses, the total percentage 100. “The probability values refer to Fisher’s Exact Test.
--
II) treated
alcoholics
Total 83 70
p
14 20 7 6 22 14
ns ns 0.03 ns 0.001 0.03
of each column
-
does not equal
Results Table 1 shows the judgments of successfully (Group I) and unsuccessfully (Group II) treated alcoholics of the effectiveness of treatment methods in percentage. In addition, totals of the subjects’ responses to both instructions asking for a judgment of the effectiveness and ineffectiveness of treatment methods are provided. The total responses of both groups of subjects indicated that there were significant differences in the frequency of judgments of effectiveness and ineffectiveness of the various treatment methods. Group therapy (54X) was the most frequently mentioned “most helpful” method of treatment, followed by individual counseling (26’6), work therapy (17’6), lectures (16%), detoxification (16%) and family therapy (13%) respectively (x2 := 42.87, df = 5, p < 0.001). The treatment method most frequently mentioned as “least helpful” was work therapy (22%), followed by lectures (20&), detoxification (14%), family therapy (14%), group therapy (7,X) and individual counseling (6%) respectively (x2 = 12.44, df = 5, p < 0.05). The frequencies of individual treatment methods differed significant2 lY(X = 31 f 43 df = 5, p < 0.001) when the responses to the instruction of “most helpful” were compared with the responses to the instruction of “least helpful”. The two groups did not differ significantly (x2 = 9.24, df = 5) in the frequencies of treatment methods judged to be “most helpful”. However, a significant difference (x2 = 20.58, df = 5, p < 0.001) between the two groups was found for the frequencies of “least helpful” treatment methods.
244
When the distribution of responses of the successfully and unsuccessfully treated groups for the judgments of most and least helpful individual treatment methods were compared by Fisher’s Exact Method, three comparisons were significant at the 0.05 level or better. These were: group therapy (p < 0.03), work therapy (p < O.OOl), and family therapy (p < 0.03).
Discussion Both groups of alcoholics judged that the six treatment methods differ in their effectiveness. As shown in the totals of the responses of the two groups of subjects, the treatment methods judged to be most effective were group therapy and individual counseling, respectively. These two methods were ranked highest in the judgments of “most helpful” treatment and lowest in “least helpful” treatment. It might be assumed that the effectiveness of both these methods is based on their effectiveness in breaking down defense mechanisms. A possible explanation of the finding that group therapy is judged to be more effective than individual counseling might be that confrontation by a peer group is more overwhelming than by a single individual. Surprisingly, no significant differences between the successfully and unsuccessfully treated alcoholics were found in the frequencies of treatments judged to be “most helpful”. This apparently paradoxical result might shed some light on the nature of the recovery process in alcoholism. It might be assumed that the recovery process in alcoholism follows the learning process. For some individuals, one treatment might be all that is required to complete the learning process. In other individuals, the learning process might be slower. Even though these patients have failed by returning to drinking after treatment, something may have been learned which facilitates further learning, increasing the likelihood of success in future treatments. Clinical experience confirms that many alcoholics attain sobriety only when they are exposed to several treatments. Mulford [6] proposed that the number of treatment attempts by an individual is one of the most powerful predictors of successful treatment outcome. Therefore, it is hypothesized that even unsuccessful treatments contribute, in themselves, to final recovery. The similarity between the judgments of successfully and unsuccessfully treated alcoholics regarding the effectiveness of group therapy might, therefore, reflect the positive effects of previous treatment in the unsuccessful group. On the other hand, the successfully and unsuccessfully treated groups showed differences in their judgments of “least helpful” treatment. This is most evident in the judgments about the effectiveness of work therapy, which differ widely between the two groups. Since work therapy consists of overt activities, with little emphasis given to interpersonal relationships, the success group might see work
245
therapy as playing a minor role in their recovery process. It could be hypothesized that the reason they did not see this experience as particularly beneficial was that work therapy did not force them to confront their defense-denial mechanism to the extent group therapy did. The treatment failure group might not be willing to admit to alcoholism. These individuals might feel more comfortable in the non-demanding atmosphere of the work therapy assignment since such an activity would not force them to face their problems, yet would occupy their empty time. According to these data, the therapeutical value of work therapy is questionable. However, a need for work therapy, or some like activity, cannot be denied. Treatment centers are always faced with the problem of occupying the patients when they are not in therapy. For this purpose, work t,herapy may well be of value. While professionals agree that the detoxification process plays an essential role within the total treatment procedure and definitely leads to patients’ improvement [7], it was rated low in effectiveness by both groups of subjects. Evidently, alcoholics do not see detoxification as helpful, because it does not address personal problems essential for the recovery from alcoholism as does group therapy. Before successful group treatment can begin, it is necessary for alcoholics to learn that they can exist physically without the use of alcohol. The detoxification procedure should concern itself with their physical needs and provide medical care for physical complications. Detoxification without further treatment is of little help. Therefore, since detoxification fulfills its most important purpose only when the patients are referred to further treatment, it is recommended that detoxification centers be evaluated on,the basis of whether such referrals actually take place. The results of this study have several implications for future research and therapy in the field of alcoholism. On the basis of the results, it appears that the problem-solving nature of treatment methods is a crucial factor in its effectiveness. It is, therefore, recommended that all therapeutical activities focus on this problem-solving process. The present study concerned itself with patients’ judgments of the effectiveness of treatment without investigating the reasons for such judgments. Future research might do well to explore, in detail, the particular reasons for the patients’ judgments of the effectiveness or ineffectiveness of a treatment method. It might also be important for future research to test the relation of a patient’s active participation in group therapy with his judgment of the effectiveness of group therapy after treatment.
References 1
E. J. Ends and C. W. Page, Group change, Psychological Monograph,
psychotherapy 1959, p. 480.
and concomitant
psychological
246 2 B. Kissin, S. Rosenblatt and S. Machover, Prognostic factors in alcoholism, Psychiatric Res. Rept., 24 (1968) 22 - 43. 3 M. B. Sobell and L. C. Sobell, Individualized behavior therapy for alcoholics; rationale, procedures, preliminary results, and appendix (California Mental Health Research Monograph No. 13) Sacramento; California Dept. Mental Hygiene, 1972. 4 D. J. Fitzgibbons, R. Cutler and J. Cohen, Patient’s self-perceived treatment needs and their relationship to background variables, J. Consult. Clin. Psychol., 37 (1971) 253 - 258. 5 D. G. Jansen, What state hospital psychiatric patients want more of and less of in treatment, J. Consult. Clin. Psychol., 41 (1973) 317. 6 H. A. Mulford, Becoming an ex-problem drinker. Presented before the 30th Intern. Congr. on Alcoholism and Drug Dependence, September 4 9, 1972. 7 H. Hoffmann, P. C. Nelson and D. N. Jackson, The effects of detoxification on psychopathology for alcoholics as measured by the Differential Personality Inventory (DPI), J. Clin. Psychol., 30 (1974) 89 - 93.
241 - 246 in the Netherlands
TREATMENT EFFECTIVENESS AS JUDGED BY SUCCESSFULLY AND IJNSUCCESSFULLY TREATED ALCOHOLICS
H. HOFFMANN,
A. A. NOEM
Willmar (MN) State (Received
Hospital,
and D. PETERSEN Willmar,
Minnesota
56201
(U.S.A.)
June 23, 1975)
Summary Thirty-seven successfully and 46 unsuccessfully treated male alcoholics were asked to judge the effectiveness or ineffectiveness of six treatment methods routinely offered by a state hospital. For each treatment method, the total frequencies of judgments of most and least helpful, respectively, were as follows: detoxification (16%, 14X), lectures (16/z , 20X), group therapy (54%, 7%), individual counseling (26%, 6%), work therapy (1770, 22%) and family therapy (13%, 14,Z). The two groups of subjects differed significantly in the frequencies of treatment methods judged to be “least helpful”, but not in the frequencies of “most helpful” treatment. The similarity between the judgments of successfully and unsuccessfully treated alcoholics might reflect the positive effects of previous treatment in the unsuccessful group.
A common method of evaluating the effectiveness of different treatment methods consists of the random assignment of subjects to two or more treatment groups and the measurement of treatment outcome, usually in terms of abstinence, by follow-up methods [l - 31. An alternative approach to treatment evaluation would be to take the patient’s feelings toward the treatment process and its effectiveness into consideration. The principle of patient feedback was considered by Fitzgibbons, Cutler and Cohen [4] in their investigation of psychiatric patients’ self-perceived treatment needs and by Jansen [ 51 in his investigation of psychiatric patients’ treatment preferences. However, such a systematic investigation of alcoholics’ conceptions of the effects of various treatment methods has not been fully implemented in treatment evaluation. The present study investigated whether or not there were differences (a) among patients’ judgments of effectiveness of routinely offered alcohol. treatment methods, and (b) between the effectiveness of various alcohol treatment methods as judged by successfully treated alcoholics and as judged by unsuccessfully treated alcoholics.
241
242
Method The subjects consisted of two groups of male alcoholics. Group I was comprised of 37 alcoholics who had formerly received treatment at Willmar State Hospital and returned there to attend an Annual Chemical Dependency Alumni Meeting. Considering that these subjects (a) attended an annual alumni meeting, (b) had a mean period of 5.3 years since their last treatment and (c) claimed sobriety, it appears reasonable to label this group a successfully treated one. Group II consisted of 46 male alcoholics who also had received treatment at Willmar State Hospital and were readmitted into treatment there on account of a relapse in drinking. These subjects were labeled a treatment failure group because of their return to drinking after treatment and subsequent readmission into treatmen The drinking patterns of the groups classified as successful and failure showed obvious differences. Relapses to drinking at any time after discharge were reported for 27% of the success group and 100% of the failure group (x2 = 53.13, df = 1, p < 0.001). One month after discharge, such relapses occurred in 10.8% of the success group and 26.1% of the failure group (x 2 = 4 . 14, df = 1, p < 0.05). At three months after discharge, 18.9% of the success group and 60.9% of the failure group (x2 = 16.57, df = 1, p < 0.001) experienced a relapse. The longest period of sobriety being more than one year was 81.1% for the success group and 6.5% for the failure group (x 2 = 50.84, df = 1, p < 0.001). With respect to the current drinking pattern, 94.6% of the success group and not one percent of the failure group reported total abstinence (x2 = 79.17, df = 1, p < 0.001). There were no significant age differences between the two groups (M, = 44.62 yr., M, = 44.76 yr., t = 0.06). However, the groups did differ significantly on the variables of years of education (M, = 11.84 yr., M2 = 9.52 yr., t = -4.77, p < 0.001) and number of married subjects (Group I = 73%, Group II = 41%, x2 = 8.30, df = 1, p < 0.01). The treatment offered by the alcoholism treatment unit was a six week, AA oriented treatment. The major treatment methods routinely offered by the treatment center were: detoxification, lectures on alcoholism and alcohol associated problems, group therapy, individual counseling conducted by counselors on alcoholism and psychologists, work therapy and family counseling. Each subject was asked to indicate on a specially composed questionnaire which of the major aspects of treatment they judged “most helpful” and which “least helpful”. All patients received all types of treatment. The test-retest reliability of individual treatment items within one week testing interval were: detoxification 0.63, lectures 0.47, group therapy 0.40, individual counseling 0.47, work therapy 0.54 and family therapy 0.47. For df = 54, all were significant at the 0.01 level of confidence or better. Subjects had the opportunity to indicate more than one treatment method as being most or least helpful. Chi-square analysis and Fisher’s Exact Method were used for the statistical analysis, as appropriate.
243
TABLE
1
CJudgments of successfully (Group I) and unsuccessfully (Group of the effectiveness of treatment methods (in percentage)“* Effectiveness
Most helpful
Least
helpful
Group N = (Subjects) No. of responses
I 37 58
II 46 60
Total 83 118
I 37 36
II 46 34
Detoxification Lectures Group therapy Individual counseling Work therapy Family therapy
14 16 59 38 8 22
17 15 50 17 24 7
16 16 54 26 17 13
14 24 0 8 43 8
15 17 13 4 4 20
‘Because of multiple responses, the total percentage 100. “The probability values refer to Fisher’s Exact Test.
--
II) treated
alcoholics
Total 83 70
p
14 20 7 6 22 14
ns ns 0.03 ns 0.001 0.03
of each column
-
does not equal
Results Table 1 shows the judgments of successfully (Group I) and unsuccessfully (Group II) treated alcoholics of the effectiveness of treatment methods in percentage. In addition, totals of the subjects’ responses to both instructions asking for a judgment of the effectiveness and ineffectiveness of treatment methods are provided. The total responses of both groups of subjects indicated that there were significant differences in the frequency of judgments of effectiveness and ineffectiveness of the various treatment methods. Group therapy (54X) was the most frequently mentioned “most helpful” method of treatment, followed by individual counseling (26’6), work therapy (17’6), lectures (16%), detoxification (16%) and family therapy (13%) respectively (x2 := 42.87, df = 5, p < 0.001). The treatment method most frequently mentioned as “least helpful” was work therapy (22%), followed by lectures (20&), detoxification (14%), family therapy (14%), group therapy (7,X) and individual counseling (6%) respectively (x2 = 12.44, df = 5, p < 0.05). The frequencies of individual treatment methods differed significant2 lY(X = 31 f 43 df = 5, p < 0.001) when the responses to the instruction of “most helpful” were compared with the responses to the instruction of “least helpful”. The two groups did not differ significantly (x2 = 9.24, df = 5) in the frequencies of treatment methods judged to be “most helpful”. However, a significant difference (x2 = 20.58, df = 5, p < 0.001) between the two groups was found for the frequencies of “least helpful” treatment methods.
244
When the distribution of responses of the successfully and unsuccessfully treated groups for the judgments of most and least helpful individual treatment methods were compared by Fisher’s Exact Method, three comparisons were significant at the 0.05 level or better. These were: group therapy (p < 0.03), work therapy (p < O.OOl), and family therapy (p < 0.03).
Discussion Both groups of alcoholics judged that the six treatment methods differ in their effectiveness. As shown in the totals of the responses of the two groups of subjects, the treatment methods judged to be most effective were group therapy and individual counseling, respectively. These two methods were ranked highest in the judgments of “most helpful” treatment and lowest in “least helpful” treatment. It might be assumed that the effectiveness of both these methods is based on their effectiveness in breaking down defense mechanisms. A possible explanation of the finding that group therapy is judged to be more effective than individual counseling might be that confrontation by a peer group is more overwhelming than by a single individual. Surprisingly, no significant differences between the successfully and unsuccessfully treated alcoholics were found in the frequencies of treatments judged to be “most helpful”. This apparently paradoxical result might shed some light on the nature of the recovery process in alcoholism. It might be assumed that the recovery process in alcoholism follows the learning process. For some individuals, one treatment might be all that is required to complete the learning process. In other individuals, the learning process might be slower. Even though these patients have failed by returning to drinking after treatment, something may have been learned which facilitates further learning, increasing the likelihood of success in future treatments. Clinical experience confirms that many alcoholics attain sobriety only when they are exposed to several treatments. Mulford [6] proposed that the number of treatment attempts by an individual is one of the most powerful predictors of successful treatment outcome. Therefore, it is hypothesized that even unsuccessful treatments contribute, in themselves, to final recovery. The similarity between the judgments of successfully and unsuccessfully treated alcoholics regarding the effectiveness of group therapy might, therefore, reflect the positive effects of previous treatment in the unsuccessful group. On the other hand, the successfully and unsuccessfully treated groups showed differences in their judgments of “least helpful” treatment. This is most evident in the judgments about the effectiveness of work therapy, which differ widely between the two groups. Since work therapy consists of overt activities, with little emphasis given to interpersonal relationships, the success group might see work
245
therapy as playing a minor role in their recovery process. It could be hypothesized that the reason they did not see this experience as particularly beneficial was that work therapy did not force them to confront their defense-denial mechanism to the extent group therapy did. The treatment failure group might not be willing to admit to alcoholism. These individuals might feel more comfortable in the non-demanding atmosphere of the work therapy assignment since such an activity would not force them to face their problems, yet would occupy their empty time. According to these data, the therapeutical value of work therapy is questionable. However, a need for work therapy, or some like activity, cannot be denied. Treatment centers are always faced with the problem of occupying the patients when they are not in therapy. For this purpose, work t,herapy may well be of value. While professionals agree that the detoxification process plays an essential role within the total treatment procedure and definitely leads to patients’ improvement [7], it was rated low in effectiveness by both groups of subjects. Evidently, alcoholics do not see detoxification as helpful, because it does not address personal problems essential for the recovery from alcoholism as does group therapy. Before successful group treatment can begin, it is necessary for alcoholics to learn that they can exist physically without the use of alcohol. The detoxification procedure should concern itself with their physical needs and provide medical care for physical complications. Detoxification without further treatment is of little help. Therefore, since detoxification fulfills its most important purpose only when the patients are referred to further treatment, it is recommended that detoxification centers be evaluated on,the basis of whether such referrals actually take place. The results of this study have several implications for future research and therapy in the field of alcoholism. On the basis of the results, it appears that the problem-solving nature of treatment methods is a crucial factor in its effectiveness. It is, therefore, recommended that all therapeutical activities focus on this problem-solving process. The present study concerned itself with patients’ judgments of the effectiveness of treatment without investigating the reasons for such judgments. Future research might do well to explore, in detail, the particular reasons for the patients’ judgments of the effectiveness or ineffectiveness of a treatment method. It might also be important for future research to test the relation of a patient’s active participation in group therapy with his judgment of the effectiveness of group therapy after treatment.
References 1
E. J. Ends and C. W. Page, Group change, Psychological Monograph,
psychotherapy 1959, p. 480.
and concomitant
psychological
246 2 B. Kissin, S. Rosenblatt and S. Machover, Prognostic factors in alcoholism, Psychiatric Res. Rept., 24 (1968) 22 - 43. 3 M. B. Sobell and L. C. Sobell, Individualized behavior therapy for alcoholics; rationale, procedures, preliminary results, and appendix (California Mental Health Research Monograph No. 13) Sacramento; California Dept. Mental Hygiene, 1972. 4 D. J. Fitzgibbons, R. Cutler and J. Cohen, Patient’s self-perceived treatment needs and their relationship to background variables, J. Consult. Clin. Psychol., 37 (1971) 253 - 258. 5 D. G. Jansen, What state hospital psychiatric patients want more of and less of in treatment, J. Consult. Clin. Psychol., 41 (1973) 317. 6 H. A. Mulford, Becoming an ex-problem drinker. Presented before the 30th Intern. Congr. on Alcoholism and Drug Dependence, September 4 9, 1972. 7 H. Hoffmann, P. C. Nelson and D. N. Jackson, The effects of detoxification on psychopathology for alcoholics as measured by the Differential Personality Inventory (DPI), J. Clin. Psychol., 30 (1974) 89 - 93.
