Alcoholics treated by individualized behavior therapy: One year treatment outcome

Fkhav. Res. &Therapy, 1973, Vol. 11, pp. 599 to 618. Pcrgamcm Press. Printed in England

ALCOHOLICS TREATED BY INDIVIDUALIZED BEHAVIOR THERAPY:

ONE YEAR TREATMENT OUTCOME*

MARK B. SOBELL? and LINDA C. S~BELL

Alcoholism Services, Orange County (Ca.) Department of Mental Health, 9842 West 13th Street, Santa Ana, California 92703, U.S.A. and University of California, Irvine,

California, U.S.A.

(Received 12 July 1973)

Summary-One-year treatment outcome results are reported for 70 male alcoholics who, while hospitalized at Patton State Hospital, served as subjects in an experiment evaluating ‘Individualized Behavior Therapy (IBT)’ techniques. Initially, subjects had been assigned to a controlled drinking or non-drinking (abstinence) treatment goal, and then were randomly assigned to either an experimental group receiving IBT or a control group receiving conventional state hospital treatment. One year follow-up results demonstrated that IBT treated subjects had functioned significantly better than control subjects. Dependent variable measures included daily drinking dis~sition, general emotional adjustment, vocational satisfaction, occupational status, driving status and an index of residential status and stability. The results support the view that some ‘alcoholics’ can acquire and maintain controlled drinking behavior over at least a 1-yr follow-up interval. The difficulties of designing and applying sophisticated follow-up procedures and measures are discussed.

IN A STUDY designed to evaluate the effects of individualized behavior therapy (Sobell and Sobell, 1972, 1973), 70 male, Gamma alcoholics (Jellinek, 1960), voluntarily hospitalized at Patton State Hospital, served as subjects in a controlled experiment. Experimental treatment procedures were designed in accordance with the rationale that heavy, abusive drinking of alcoholic beverages is appropriately considered to be a discriminated, operant behavior, and that treatment procedures should be tailored whenever possible to meet the specific needs of each subject.

The experimental design used in the study is outlined in Fig. 1. Initially, subjects were interviewed by the research staff and assigned to a treatment goal of either non-drinking (abstinence) or controlled drinking, whichever was considered most appropriate. The criteria used for treatment goal assignment are included in the original experimental reports. Thirty subjects were assigned to the non-drinking treatment goal, and 40 subjects were assigned to the controlled drinking goal. Subjects within each treatment goal condition were then randomly assigned to either an experimental group receiving 17 experimental treatment sessions, or a control group receiving conventional state hospital treatment

* This work was supported, in part, by Public Health Service Grants 1 R01 MH 16547 and 1 R18 MH 23169. Portions of this paper, using preliminary data, were presented at the 80th Annual Meeting of the American Psychological Association in Honolulu, Hawaii in 1972. The authors express appreciation to Fred SamueIs. Natalie Olsen. Robert Akamine and the numerous individu~s and agencies who urovided follow-up inf~~ation.

7 Requests for reprints should be addressed to Mark B. Sobell, Orange County Alcoholism Services, 9842 West 13th Street, Santa Ana, California, U.S.A., 92703.

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ALCOHOLICS TREATED BY INDIVIDUALIZED BEHAVIOR METHOD 601

oriented to abstinence. Essentially, then, there were two expe~mental treatment programs- non-drinking and controlled drinking-each with appropriate control groups.

The experimental treatment procedures will be summarized, as they are described in earlier reports and are quite complex. Procedures included subjects being videotaped while intoxicated under experimental conditions, providing subjects when sober with videotape self-confrontation of their own drunken behaviors, shaping of appropriate controlled drinking or non-drinking behaviors respective to treatment goal, the availability of alcoholic beverages throughout treatment, and behavior change training sessions. ‘Behavior change training sessions’ is a summary phrase to describe sessions which concentrated upon determining setting events for each subject’s drinking, training the subject to generate a series of possible alternative responses to those situations, to evaluate each of the delineated alternatives for potential short- and long-term consequences, and then to exercise the response which could be expected to incur the fewest self-destructive long-term consequences. Behavior change training sessions consisted of discussion, role playing, assertiveness training, role reversal or other appropriate behavioral techniques, respective to the topics under consideration during a given session.

Control subjects received conventional treatment procedures which could include group therapy, chemotherapy, Alcoholics Anonymous, physiotherapy and other traditional services. A &month post-discharge follow-up of subjects showed that experimental subjects functioned significantly better than control subjects, regardless of treatment goal.

This report presents continued and more extensive follow-up results for the first I-yr period following each subject’s discharge from the hospital.

METHOD

The basic procedures used for follow-up have been outhned elsewhere (Sobell and Sobell, 1972). Basically, each subject and as many respective ‘collateral information sources’ as possible were contacted every 3-4 weeks throughout the entire foIlow-up interval. Collateral information sources are defined as any relative, friend, public or private agency, employer or other individual who had had contact with a subject. While follow-up interviews were regularly conducted every 3-4 weeks, subjects and collaterals were usually unaware of the exact date and time they would be contacted. The following examples demonstrate the intensive nature of the follow-up procedures:

(1) Every 2 months throughout the follow-up interval, criminal records (‘rap sheets’) were obtained for all subjects. Specifically, ‘rap sheets’ include records of both the California Bureau of Criminal Identi~cation and Investigation, and of the Federal Bureau of Investigation. Additionahy, each subject’s driver’s record was obtained from the California Department of Motor Vehicles. Out-of-state motor vehicle violations, accidents and arrests are included in these records.

(2) All jail or hospital incarcerations of subjects were verified by contacting the holding facility, and thus the relation of the incarceration to aberrant drinking was obtained.

(3) Subjects were tracked to geographic locations as disparate as Virginia, Texas, Montana, Louisiana, Hawaii, the Canary Islands, Italy and Spain. In these cases, contact with subjects was usually maintained by letter and often by phone interview.

(4) In several cases, as many as 10 or 11 collateral information sources were used to cor- roborate follow-up results for a single subject, and for one subject, 15 collateral sources

602 MARK B. SOBELL and LINDA c. SOBELL

were contacted. In almost all cases, collaterals were not interviewed in the presence of subjects.

(5) The multitude of public and private agencies and individuals who provided information on subjects are too numerous to all be cited here. A brief enumeration of agencies contacted includes the Department of Human Resources Development, various credit bureaus, the Veterans Administration, telephone companies, the Social Security Administration, Bureaus of Vital Statistics and Records, Welfare Departments, munici- pal courts and the California Bureau of Biostatistics.

Measures of treatment outcome Each time that a subject or a collateral information source called or was contacted,

various information was obtained concerning the subject’s functioning since the last follow- up contact. Dependent variable measures of treatment outcome for which reports were obtained included :

(1) The subject’s daily drinking disposition since the last follow-up contact was ascertained. Subjects and collaterals were never aware of the criterion definitions used by the investigators, and were only asked: “How many days since our last contact you have

(has -, for collaterals) had anything to drink?” The specific drinking which had occurred was then described. This information was coded to consist of: (a) drunk days, defined as any day during which 10 or more oz of 86-proof liquor or its equivalent in alcohol content were consumed, or any sequence longer than 2 consecutive days when between 7 and 9 oz were consumed on each day; (b) controlled drinking days, defined as any days during which 6 oz or less of 86-proof liquor or its equivalent in alcohol content were consumed, or any isolated 1 or 2 day sequence when between 7 and 9 oz were consumed each day (this special contingency, included to allow for weekend or holiday indulgence, proved to be virtually unnecessary for categorizing treatment outcome); (c) abstinent days, defined as no ingestion of any alcohol; (d) incarcerated days in jail resulting from an alcohol-related arrest; and (e) incarcerated days in a hospital because of alcohol-related health problems (usually for detoxification).

(2) An evaluation of whether the subject’s general adjustment to interpersonal relation- ships and stressful situations was ‘Improved,’ the ‘Same,’ or ‘Worse’ as compared to the year preceding his hospitalization. This measure was obtained every 6 months from the collateral information source who had had the most frequent and extended contact with the subject and the best opportunity to evaluate his total functioning.

(3) The nature of each subject’s vocational activities during the majority of each 6 month interval was ascertained. Occupational status could be categorized as full-time employment, part-time employment, retired, physically disabled, student, on welfare or unemployed. Corroboration by collateral sources (e.g. employers) was always sought. In rare instances when contradictions were found in ratings, the best justified rating was used.

(4) Each subject evaluated his own vocational status for the greater part of each 6 month interval, compared to the year preceding his hospitalization. Status could be character- ized as ‘Improved,’ the ‘Same’ or ‘Worse’ in terms of type of duties, pay, hours worked, supervision, etc.

(5) Driver’s license status and all motor vehicle violations which occurred during the follow- up interval were recorded for each subject.

ALCOHOLICS TREATED BY INDIVIDUALIZED BEHAVIOR METHOR 603

(6) An index of each subject’s residential status and stability over the first 12 months of follow-up was computed. This trial measure was designed on the basis that a subject’s length of residence at a single location, and the nature of that residence, may reflect the subject’s degree of successful functioning. Therefore, for each subject a ‘Residential Status and Stability Index (RSSI)’ was computed using the formula:

(1)

In equation 1, It represents a subject’s length of residence at any particular shelter (i), coded as:

(1) Residence greater than or equal to 6 months (30 days/month). (2) Residence less than 6 months, but greater than or equal to 4 months. (3) Residence less than 4 months, but greater than or equal to 1 month. (4) Residence of less than 1 month.

Also in equation 1, s1 represents the status of a particular shelter (i) coded as:

(1)

(2)

(3)

Permanent housing, defined as any residence where rent or payment occurs on a monthly basis (usually a home or apartment). Transitionaf housing, defined as any residence where rent is usually required on a weekly or daily basis and where there is an expectancy that residence wiI1 be ephe- meral (e.g. recovery houses, non-skid row motels and hotels, Salvation Army, Rescue Missions, YMCA, etc.). Skid-row housing, defined as a definite skid-row hotel or motel, a car or as no shelter.

Finally, in equation 1, ‘Opp. to reside’ represents the opportunity of a given subject to seek shelter and is computed as:

Opportunity to reside = 1 - [proportion of follow-up interval incarcerated] (2)

Thus defined, the RSSI has a range from 1 (highest residential status and stability) to approaching 0 (as residential status and stability near total impairment).

(7) Another trial measure concerned whether subjects made any use of outpatient therapeutic supports (e.g. Alcoholics Anonymous, outpatient counseling, vocational rehabili- tation, etc.) during each 6 month follow-up interval No specific hypotheses were entertained about the relationship of this variable to other treatment outcome measures.

(8) At the end of each 6 month interval, both groups of experimental subjects were asked if they still retained their ‘Research Program Do’s and Do Not’s Card’ presented to them at the conclusion of their treatment.

Discrepancies between reports of subjects and collaterals, between reports from different collaterals, or between subjects or collaterals and official records, were always extensively probed, with the final rating being determined by the most objective supporting information available.

604 MARKB.SORELL and LINDA c. SOBELL

RESULTS

Table t presents the number of subjects in each of the four experimental conditions who were followed throughout each of the first (months I-6) and second (months 7-12) 6-month

TABLE 1. NUMBER OFSUBJECTS LOCATED FOR FOLLOW-UP,PERCENTAOE OFCASESINWHICH

ONE OR MORE COLLATERAL INFORMATION SOURCES WERE INTERVIEWED, AND THE MEAN

NUMBER OFCOLLATERALINFORMATIONSOURCESINTERVIEWED PERSUBJECT FOR SUBJECTSIN

EACH EXPERIMENTAL CONDITION DURING THE FIRST AND SECOND ~-MONTH EOLLOW-UP

INTERVALS

One or more collateral sources Mean number

Subjects interviewed of coftatewIs N found f%f interviewed

Follow-up Months J-6

CD-E 20 100.00 3.75 CD-C ::: 19 95.00 4.21

ND-E 15 15 100.00 5.26 ND-C 1.5 1st 100.00 3.79

Total 70 69 98.57 4.21 -_

Follow-up Months 7-12

CD-E 20 20 Joo.00 3.90 CD-C 20 19 95.00 5.16

ND-E 15 JOO.00 6.6t.J ND-C :5 J-V IOD.00 4.86

Total 70 69 98.57 5.04

* Experimental conditions were controlled drinker experimental (CD-E); controlled drinker control (CD-C); non-drinker experimental (ND-E); and non-drinker control (ND-C).

t Includes one subject who died 8 weeks following discharge. See text.

follow-up intervals, the percentage of subjects in each group for whom one or more coi- lateral information sources were interviewed, and the mean number of collateral sources contacted for fotlow-up interviews regarding each group of subjects. Treatment outcome data were obtained for 69 of the 70 total subjects, and at least one collateral information source was interviewed for each subject found. It was confirmed that the one controlled drinker control subject who could not be located for foliow-up had not been reported arrested or imprisoned within the United States, nor was he reported deceased by any state or by the Social Security Administration. Further, he had not been employed in California during the follow-up period.

Drinkhg behauior meawes One rough measure of drinking behavior outcome consisted of cafculating the proportion

of subjects in each group who were functioning well (abstinent plus controlled drinking


days) during the majority of the 1st yr follow-up interval. Eighty-five per cent of the controlled drinker experimental subjects functioned well, as compared to 31.58 per cent of the controlled drinker control subjects. Similar results were found for non-drinker subjects as 86.67 per cent of the experimental subjects functioned well while only 26.67 per cent of the control subjects did so. Fisher-Yates Exact Probability Tests (McNemar, 1962) were used to analyze the differences between respective experimental and control subjects with groups dichotomized into subjects functioning well, and subjects not functioning well (drunk days and incarcerated days, or deceased due to alcohol or drug-related causes). In both cases, differences between experimental and control groups were statistically significant

beyond the 0.05 alpha error level. By evaluating daily drinking disposition, a more sensitive measure of treatment outcome

using drinking behavior as a dependent variable is obtained. Thus, for the 1st follow-up yr (366 days), the 20 controlled drinker experimental subjects functioned well for a mean of 70.48 per cent of all days, as compared to a mean of 35.22 per cent of all days spent tunctioning well during the same interval by the 19 controlled drinker control subjects. This difference is statistically significant (t 37 = +33.33, p < 0.005). Similarly, during the 1 yr interval, the 15 non-drinker experimental subjects functioned well for a mean of 68.39 per cent of all days while the 14 non-drinker control subjects functioned well for a mean of 38.48 per cent of all days. The circumstances concerning the barbiturate-related death of one of the non-drinker control subjects have been discussed elsewhere (Sobell and Sobell, 1972, 1 173), and data for that subject have not been included in this analysis. The difference between non-drinker experimental and control subjects is statistically significant (& = +3.55, p < 0.005).

To evaluate trends in the data, the percentages of days that each individual subject functioned well during consecutive 6-month (183 day) follow-up periods are presented graphically in Fig. 2 for controlled drinker subjects, and in Fig. 3 for non-drinker subjects. The data for controlled drinker subjects present an interesting pattern, as it appears that results for the experimental subjects are becoming somewhat dichotomized during the second 6-month interval. During that period, 13 of the 20 total experimental subjects functioned well for over 89 per cent of all days, while 4 of the remaining subjects failed to function well for even 10 per cent of the interval. However, this trend is not readily apparent in the data for the other three experimental groups, although it does appear that non-drinker experimental subjects may be starting to form a similar pattern. It remains to be seen whether the apparent dichotomy will be maintained throughout the second follow- up year.

In order to determine if treatment outcome results from a subject’s first 6-month follow- up interval were a significant predictor of later functioning, tests for linear regression (Hays, 1963) were computed using as data the percentage of days functioning well by each individual subject over each of the two consecutive 6-month follow-up intervals. Except for the non-drinker control group, there was significant linear prediction from the first to the second follow-up interval within each of the other three experimental conditions. Thus, drinking data for post-discharge months l-6 significantly predicted the drinking results for the second follow-up period, months 7-12 (CD-E: b = +0.85, t,, = +2.39, p < 0.05; CD-C: b = 1-0.67, t,, = +4.35, p < 0.001; ND-E: b = +0.73, t,, = +2.97, p < 0.01). Results for the non-drinker control subjects approached statistical significance (b = +0.37 t12 = + 1.61, p < O.lO), and may possibly be significant when two year follow-up results are complete.

BRT. 1 l/4-


FIG. 2. Percentage of days spent functioning well (abstinent or controlled drinking) by individual controlled drinker experimental and control subjects during each of two consecutive

dmonth (183 day) follow-up intervals.

FIG. 3. Percentage of days spent functioning well (abstinent or controlled drinking) by individual non-drinker experimental and controt subjects during each of two consecutive 6-month

(183 day) follow-up intervals.

ALCOHOLICS TREATED BY INDIVIDUALiZED BEHAVIOR METHOD 607

Table 2 presents a more detailed analysis of drinking behavior which includes the mean percentage of days spent in each defined drinking disposition by subjects for each experimental condition during both the first and second 6-month follow-up intervals, and over the entire 1st yr of follow-up. Generally, experimental subjects experienced considerably fewer drunk days during follow-up periods, compared to their respective control subjects. All groups had a diminished number of controlled drinking days during the second 6-months as compared to the first, and this data will be examined in more detail later in this paper. Total days incarcerated for alcohol-related reasons remained relatively equal between experimental subjects and their respective controls. As in earlier follow-up reports, experimental subjects were more often incarcerated in hospitals than in jails, whiie the reverse relationship was still maintained for control subjects. Preliminary 2nd yr data indicate that the number of days incarcerated will decrease radically for both groups of controlled drinker subjects, while the incidence of incarceration for non-drinker subjects will probably be relatively unchanged.

The nature and frequency of controlled drinking which occurred is, naturally, one of the most controversial elements of this study. During the first 6-month follow-up interval, each group had at least one member who successfully practiced controlled drinking. As anticipated, however, the controlled drinker experimental subjects successfully practiced controlled drinking to a considerably greater extent. The reported incidence of controlled drinking occurring among subjects in all treatment groups is not surprising, as it is relatively consistent with a number of other follow-up studies in the literature (reviewed in Sobell and Sobell, 1972) which reported a small proportion of subjects able to practice limited drinking even though they had participated in treatment programs oriented to abstinence, I-Iowever, during the second 6-month interval, the incidence of controlled drinking decreased severely for all groups except the controlled drinker experimental subjects.

Specifically, the number of subjects in each group who successfully engaged in at least 1 day of controlled drinking during the 1 st yr of follow-up was as follows: all 20 controlled drinker experimental subjects, I1 of the 19 controlled drinker control subjects, nine of the 15 non-drinker experimental subjects, and seven of the 15 non-drinker control subjects.

To the authors’ knowledge, n,‘t treatment outcome study has ever been conducted where the frequency and nature of daily drinking was recorded. Lacking precedent, therefore, it is impossible to evaluate whether the incidence of controlled drinking days found among control subjects was unique to this study or typical of post-hospitalization findings. Since there were a number of controlled drinking days engaged in by subjects in all groups, it is of interest to determine how such behavior was related to functioning throughout the interval. In Table 3, the mean percentage of days spent in various drinking dispositions are displayed for subjects from each experimental condition for the first and second 6-month follow-up intervals, with subjects categorized according to whether they engaged in no controlled drinking days, some but fewer than 5 per cent (9 or less days) controlled drinking days, or greater than 5 per cent controlled drinking days during each interval. In each case except one, subjects who were able to successfully engage in 5 per cent or greater controlled drinking days during the 6-month follow-up interval functioned better than other subjects in their group. The one exception which occurred during the second 6-month interval involved two non-drinker control subjects who practiced controlled drinking for greater than 5 per cent of those days. Tabular results were derived from combining the data of one subject who functioned well for 93.44 per cent of all days with data from another subject who functioned well for only 9.28 per cent of all days. There was no other case in which

608 MARK B. SOBELL and LINDA C. SOBELL

TABLE 2. MEAN PERCENTAGE OF DAYS SPENT IN DIFFERENT DRINKING DISPOSITIONS BY SUBJECTS IN FOUR EXPERIMENTAL GROUPS DISPLAYED SEPARATELY FOR THE FIRST AND SECOND &MONTH

(183 DAY) FOLLOW-UP INTERVALS, AND FOR THE TOTAL 1st YR (366 DAY) FOLLOW-UP PERIOD

Experimental condition*

Drinking disposition CD-E CD-c ND-E ND-CT

Follow-up Months l-6:

Controlled drinking 27.81 13.83 4.05 11.83 Abstinent, not incarcerated 40.55 24.77 66.15 22.32

Drunk 18.55 48.60 15.34 39.34 Incarcerated, alcohol-related: Hospital 11.15 3.57 10.27 9.45

Jail 1.94 9.23 4.19 17.06

Total 100.00 100.00 100.00 100.00


Controlled drinking Abstinent, not incarcerated

Drunk Incarcerated, alcohol-related: Hospital

Jail

Total

Follow-up Year 1 (Months 1-12)

22.57 5.29 2.59 3.09 50.02 26.55 64.00 39.73

9.48 51.17 15.34 40.36 11.53 7.53 10.27 3.12 6.40 9.46 4.19 13.70

100.00 100.00 100.00 100.00

Controlled drinking 25.19 9.56 3.33 6.13 Abstinent, not incarcerated 45.29 25.66 65.06 32.35

Drunk 14.02 49.88 13.99 39.85 Incarcerated, alcohol-related: Hospital 11.34 5.55 11.77 6.29

Jail 4.16 9.35 5.85 15.38

Total 100.00 100.00 100.00 100.00

* Experimental conditions were controlled drinker experimental (CD-E), N = 20; controlled drinker control (CD-C), N = 19; non-drinker experimental (ND-E), N = 15; and, non-drinker control (ND-C), N = 14.

t Does not include data for one ND-C subject who died of drug-related causes about 8 weeks after hospital discharge.

3 Very minor differences between results previously reported for follow-up months 1-6 (Sobell and Sobell, 1972) and similar data appearing in this table resulted from added information not available to the authors when the earlier publication was prepared. In no case did corrected information constitute serious changes in treatment outcome conclusions.

variance among subjects in a group approached this degree of dispersion. Except for controlled drinker experimental subjects, Table 3 also indicates that fewer subjects engaged in significant controlled drinking during the second 6-month interval than during the first. It is interesting to note that for all groups except the non-drinker experimental subjects, those subjects who never engaged in controlled drinking at any time during the follow-up interval usually functioned considerably less well than other subjects in their respective

group.

ALCOHOLICS TREATED BY INDIVIDWALIZED BEHAVIOR METHOD 609

TABLE 3. MEAN PERCENTAGE OF DAYS SPENT IN VARIOUS DRINKING DISPOSITIONS DURING FIRST AND SECOND

6-MONTFi (183 DAY) FOLLOW-Up INTERVALS BY SuBJECTS IN DlFFERENT EXPE~M~~~ CONDITIONS CATEGORIZED

ACCORDING TO WHETHER THEY HAD NO CONTROLLED DRINKING (CD) DAYS DURING THE FOLLOW-UP INTERVALS,

SOME BUT LESS THAN 5 PER CENT CD DAYS QURING THE INTERVAL, OR GREATER THAN 5 PER CENT CD DAYS

DURING THE INTERVAL

Experimental condition* No CD days

Drinking disposition (N) (%)

Follow-up Months l-6

< 5 %j CD days >5%CDdays All Ss

(N) (%) (N) (%) (N) (%)

CD-E: Functioning well? 0 - 4 50.67 16 72.78 20 68.36 Incarcerated - 25.69 9.94 13.09 Drunk - 23.64 17.28 18.55

Total 0 - 4 100.00 16 100.00 20 100.00

CD-C : Functioning well 9 11.23 3 47.18 7 70.09 19 38.60 Incarcerated 21.07 5.64 5.23 12.80 Drunk 67.70 47.18 24.68 48.60

Total 9 100.00 3 lOB.00 7 100.00 19 100.00

ND-E: Functioning well 7 71.89 5 64.15 3 76.30 15 70.20 Incarcerated 12.03 24.81 2.93 14.46 Drunk 16.08 11.04 20.77 15.34

TotaI 7 100.00 5 100.00 3 100.00 15 100.00

ND-C: : Functioning well 7 24.90 3 13.85 4 65.58 14 34.15 Incarcerated 30.92 51.36 0.14 26.51 Drunk 44.18 34.79 34.28 39.34

Total 7 100.00 3 100.00 4 100.00 14 100.00


CD-E: Functioning well 4 18.85 1 1.10 15 91.69 20 72.59 Incarcerated 59.70 97.80 1.46 17.93 Drunk 21.45 1.10 6.85 9.48

Total 4 100.00 1 100.00 15 100.00 20 100.00

CD-C : Functioning we11 12 24.73 4 39.21 3 50.45 19 31.84 Incarcerated 23.17 9.01 0.55 16.99 Drunk 51.50 51.78 49.00 51.17

Total 12 100.00 4 100.00 3 100.00 19 100.00

610

TABLE 3-continued

MARK B. SOBELL and LINDA C.SOBELL

Experimental condition* No CD days

Drinking disposition (N) (%)

< 5 % CD days 2 5% CD days

(N) (%) (N) (%)

All Ss

(N) (%)

ND-E : Functioning well 11 65.17 2 57.11 2 83.88 1.5 66.59 Incarcerated 21.60 32.24 4.65 20.76 Drunk 13.23 10.65 11.47 12.65

Total 11 100.00 2 100.00 2 100.00 15 100.00

ND-C:: : Functioning well 11 38.64 1 71.59 2 51.36 14 42.82 Incarcerated 20.77 0.00 3.55 16.82 Drunk 40.59 28.41 45.09 40.36

Total 11 100.00 1 100.00 2 100.00 14 100.00

* Experimental conditions were controlled drinker experimental (CD-E); controlled drinker control CD-C); non-drinker experimental (ND-E); and non-drinker control (ND-C).

t Functioning well includes days when drinking disposition was abstinent or controlled drinking. $ Does not include data for one ND-C subject who died of drug-related causes about 8 weeks after hospital

discharge.

Adjunctive measures of treatment outcome

Pattison et al. (1968) and Belasco (1971), among others, have demonstrated that changes in drinking behavior do not necessarily imply or reflect that an individual has improved in other areas of life functioning. Table 4 presents 1st yr treatment outcome results for several adjuctive measures of functioning. Data for all measures are presented separately for the first and second 6-month follow-up intervals with the exception of the dependent variable measures concerning residential status and stability, and driving status which are displayed for the entire 12 month interval.

Group differences for the variable of general adjustment as evaluated by a knowledgeable collateral information source were statistically significant between respective experimental and control groups at each follow-up interval (p < 0.05). Fisher-Yates Exact Probability Tests were used to analyze the results from two-by-two contingency tables formed by com- paring the percentage of subjects in each group rated ‘Improved’ at each interval with pooled subjects rated as ‘Same’ and ‘Worse’. It was necessary to pool the latter two categories in order to obtain a sufficient number of subjects in each category.

At all follow-up intervals, the vocational status variable was similar to that of general adjustment in that more experimental subjects rated their vocational status as ‘Improved’ during the interval than did their respective control subjects. However, the differences between groups were not large enough to be statistically significant when analyzed by Fisher-Yates Exact Probability Tests in the same manner as the general adjustment variable.

A second measure of vocational adjustment which appears in Table 4 is the actual type of employment, or non-employment, of subjects during the majority of each follow-up interval. In all cases, there are fewer unemployed subjects in the experimental groups than in their respective control groups. Because of the small number of subjects in many of the vocational categories, no statistical analyses were performed using these data.

ALCOHOLICS TREATED BY INDIVIDUALIZED BBHAVIOR METHOD 611

TABLE 4. ADJUNC~VE MEASURES OF TREATMENT OUTCOME FOR SUBJECTS IN FOUR EXPE~MENTAL GROUPS OVER FIRST AND SECOND 6-MONTH (183 DAY) FOLLOW-UP INTERVALS, OR FIRST FOLLOW-UP YEAR (366 DAY)

Experimental condition*

Adjunctive measure CD-E CD-C ND-E ND-C

Follow-up months l-6?

Evaluation of general adjustment by collaterals: Improved

Same Worse

Vocational status: Improved Same Worse

Occupational status: Full-time work Part-time work Retired Student Disabled Unemployed

Use of therapeutic supports: Yes No

Retain research program card : Yes

(%I (%I 90.00 31.58 10.00 42.11 0.00 26.31

40.00 21.05 60.00 68.42 0.00 10.53

40.00 31.58 15.00 10.53 5.00 5.26 5.00 0.00 0.00 0.00

40.00 52.63

40.00 10.53 60.00 89.47

90.00 N.A.

$35; 26:67 0.00

53.33 40.00

6.67

40.00 26.67 0.00 0.00 6.67

26.67

100.00 0.00

86.67

(%) 21.43 57.14 21.43

7.14 85.71

7.14

21.43 14.28 0.00 0.00 0.00

64.29

28.57 71.43

N.A.

Follow-up months 7-12

Evaluation of general adjustment by collaterals Improved

Same Worse

Vocational status: Improved Same Worse

Occupational status: Full-time work Part-time work Retired Student Disabled Unemployed

Use of therapeutic supports: Yes No

Retain research program card : Yes

(%I (%I 80.00 36.84 10.00 31.58 10.00 31.58

50.00 26.31 45.00 31.58

5.00 42.11

35.00 36.84 30.00 10.53

5.00 5.26 5.00 0.00 5.00 0.00

20.00 47.41

35.00 31.58 65.00 68.42

90.00 N.A.

(%) (%) 66.67 28.57 33.33 50.00 0.00 21.43

46.67 21.43 46.67 71.43

6.67 7.14

40.00 35.71 13.33 7.14 0.00 0.00 6.67 0.00 6.67 0.00

33.33 57.14

93.33 50.00 6.67 50.00

86.67 N.A.

Follow-up year 1 (months l-12)

Mean residential stability and status index (1.0 = ideal):

Drinking-relate driving violations per driver:

Valid driver’s license: Begin 1 year End 1 year

0.2619 0.1692 0.2468 0.1597

0.3125 0.5000 0.5455 0.5000$

(%) (%) (%) (%) 70.00 60.00 80.00 53.33 80.00 50.00 66.67 50.00~

* Experimental conditions were controlled drinker experimental (CD-E), N = 20; controlied drinker control (CD-C), N = 19; non-drinker experimental (ND-E), N = 15; and, non-drinker control (ND-C), N= 14.

t Minor differences between results previously reported for months l-6 (Sobell and Sobell, 1972) and similar data appearing in this table resulted from added information not available to the authors when the earlier publication was prepared.

$ This presentation does not include data for the ND-C subject who died of drug-related causes in a traffic accident shortly after his hospital discharge.

612 MARK B. SOBELL and LINDA C. SOBELL

One other variable was used to compare experimental and control subjects over consecutive &month intervals. This measure, use of therapeutic supports during the follow-up period, is perhaps the hardest to interpret of the measures used. For non-drinker subjects, where ample community resources are available to qualify as therapeutic supports (most notably, Alcoholics Anonymous and associated organizations), this is not the case, and non-drinker groups are clearly differentiated in the results. All 15 of the non-drinker experimental subjects utilized therapeutic supports during the majority of at least one of the &month follow-up intervals. This is not surprising, however, as they had been advised to do this as part of their experimental treatment. In 11 cases, subjects utilized AA in addition to other types of services such as recovery houses, outpatient counseling, Antabuse (disul- firam), etc. Three of the remaining non-drinker experimental subjects used only psychotherapeutically oriented services, and the remaining subject used a recovery house which was not affiliated with AA. During the first follow-up year, eight of 14 non-drinker control subjects used therapeutic supports during the majority of at least one of the 6-month follow-up intervals. Six subjects used AA in conjunction with other services, while one subject used outpatient counseling, and the remaining subject stayed in a recovery house not affiliated with AA.

There is some question as to whether or not the measure of use of therapeutic supports is appropriate for use with controlled drinker experimental subjects, as relatively fewer after- care services exist which will support this kind of behavior as compared to abstinence. How- ever, even with this context, with controlled drinker control subjects having available a far greater number of resources that were congruent with their treatment orientation (abstinence), more controlled drinker experimental subjects used therapeutic supports during the majority of each interval than did controlled drinker control subjects. Eight of the 20 controlled drinker experimental subjects used supports during at least one of the intervals, but only one of those subjects used AA as a resource. Five of the subjects used psychotherapeutically oriented services, one subject used a recovery house not affiliated with AA, and the remaining subject used the services of a private physician. OnIy seven of the 19 controlled drinker control subjects used therapeutic supports, and this occurred mostly during the second 6-month follow-up period. Two of those subjects used AA concomittant with their stay at an AA oriented recovery house, one subject used outpatient counseling, one used combined outpatient counseling plus clergy counseling, and the three remaining subjects utilized other (e.g. Salvation Army) resources. It is not surprising that subjects in both of these groups made little use of Alcoholics Anonymous, as one of the critical variables for their having been assigned to a controlled drinking treatment goal was a sincere dissatisfaction with that organization and with traditional treatment modalities.

Residential status and stability as an index of treatment outcome was evaluated for the entire l-yr interval, with the individual index for subjects calculated according to the procedures described earlier in this paper (see method). The mean RSSI for each group is included in Table 4. While differences between respective experimental and control groups were in the predicted direction, t-tests were not found to be statistically significant at this time. It is encouraging to note, however, that this measure was found to correlate significantly with drinking behavior represented by the percentage of days each subject spent functioning well (I = 10.35, p < 0.01).

Two other variables measured for the entire 1st yr follow-up interval only concerned the possession of a valid driver’s license, and the ratio of drinking-related driving violations (drunk driving, open container in car) per driver. These variables will not be evaluated


statistically until 2 yr follow-up is complete. At that time, it will also be necessary to determine how to appropriately analyze that data to include the severity of drinking-related accidents. To date, several control subjects have been involved in serious accidents which occurred while they were driving under the influence of alcohol. For instance, one controlled drinker control subject was driving in foggy weather while intoxicated and became involved in a multiple car collision which resulted in his suffering severe, scarring facial cuts and a partially severed optic nerve which left him permanently blind in one eye and with 10 per cent vision in his remaining eye. Similarly, one non-drinker control subject was involved in a felony hit and run accident when drunk and received over 150 stitches for lacerations of the face. Another non-drinker control subject was driving along a mountain road when drunk, failed to negotiate a curve and plummeted into a deep roadside ditch. As a consequence of that accident, he spent over 6 months in an entire body cast and now faces a series of corrective surgeries. Finally, as has been previously reported (Sobell and Sobell, 1972, 1973), one non-drinker control subject was killed in a single car traffic accident while he was under the heavy influence of barbiturates. In contrast, no controlled drinker experimental subject was involved in an injury traffic accident, and only one non-drinker experimental subject suffered a traffic injury, having broken his leg while falling off of a motorcycle. This subject was not drinking, however, at the time of that accident.

The last variable of interest concerned whether experimental subjects retained their research program card (Do’s and Don’ts card) after discharge from the hospital. As is evident in Table 4, the vast majority of subjects in each experimental group did retain their card throughout the 1st yr of follow-up. This variable cannot be used for comparison of experimental with control subjects, as control subjects did not receive cards.

DISCUSSION

The results of this study support the general conclusion that hospitalized alcoholic subjects who received the program of individualized behavior therapy functioned significantly better for the first 12. months following their discharge from treatment than did those subjects who received only conventional treatment. It is important to recognize that all of the subjects in this experiment qualified for the descriptive title of chronic, Gamma alcoholics (Jellinek, 1960). That is, prior to treatment they had all reported reaching a point where they were unable to control their drinking, and all had experienced some degree of physiological withdrawal symptoms due to the absence of alcohol.

It is of major importance that this study included one group of experimental subjects who were trained in and encouraged to practice controlled drinking as part of their treatment. The outcome data reflect their successful capacity to acquire and sustain such behavior. These conclusions are evidenced not only in differences between groups in the target behavior of drinking, but also supported by a number of adjunctive measures of life functioning. Unfortunately, daily drinking baseline data are not available for normal drinkers in the general population, and thus it is difficult to determine how well the subjects in this experiment approximated societal drinking norms, much less those of a sub-sample of the general population selected to constitute an appropriate matched normal drinker control group.

A recent report by Crawford et al. (1973) presents an excellent critical evaluation of the current status of treatment outcome study methodology and measures in

614 MARK B.SOBELL and LINDA CSOBELL

the field of alcoholism treatment. They found existing procedures and measures to be so inadequate as to “. . . cast doubt on the integrity of the reported results fp. i)_” An attempt was made in this study to explicitly avoid using unrepresentative measures of drinking behavior, such as probe-day-status procedures, and also to avoid using non-operationally defined descriptive categories such as drunk, sober or improved drinking. A measure of daily drinking disposition, while subject to slight imprecision due to memory defects, is much preferred to formerly popular procedures, such as asking a subject how long it has been since he was last drunk (reports by alcoholic individuals are likely to find that while being ‘drunk’ is defined as including highly excessive drinking, being ‘sober’ is not necessarily synonymous with being abstinent). Similarly, it is quite conceivable that the kind of outcome results one obtains may often be somewhat determined by the types of treatment outcome measures used. If an investigator, when interviewing an alcoholic individual for follow-up data, explicitly or covertly implies that the subject is expected to have been either ‘dry’ or ‘drunk’, it is highly unlikely that the subject will readily convey information concerning instances where he has successfully been able to consume limited amounts of alcohol. It is interesting to note that of the numerous studies reporting resumed but limited drinking by former alcoholics, many either allowed for that possibility to be manifested in the outcome measures used or reported the findings as anecdotal and with great surprise.

Adjunctive dependent variable measures of other areas of life functioning were included in this treatment outcome study because changes in drinking behavior which are not associated with changes in other aspects of life functioning have been demonstrate to be of questionable value (Pattison et at., 1968; IBelasco, 1971). A further considera~on of the theoretical orientation upon which this study’s treatment intervention was based predicts that succ~sful inte~entio~ will frequently be associated with other changes in life functioning for an individual. These associated changes would result from learning appropriate alternative responses to situations which once functioned as discriminative stimuli for drinking. Still, the measures and methods developed for use in this study are merely a beginning, and better refined and tested measures and procedures are a serious requirement for increasing the value of treatment outcome evaluations.

An interesting aspect of these follow-up results concerns the incidence of incarceration among subjects in each of the four experimental conditions. The amount of time spent incarcerated by subjects during the initial 12 months of follow-up appears to have been relatively high. Again, we are at a loss to determi~le whether or not such a pattern is grossly abnormal for individuals attempting to stabilize their lives following discharge from a state hospital for treatment of alcoholism. Once again, statistical baseline data describing an appropriate control population of non-alcoholic drinkers according to treatment outcome measures of functioning would be valuable for evaluating the total effect of a treatment.

Another aspect of follow-up for which little precedent exists in the literature concerns the procedures which were used in actually gathering outcome data. Primary among these are the extensive number of collateral information sources who were interviewed for each subject. The heavy reliance upon confirmation of subject self-reports by collaterals was made necessary, in part, by the use of only one interviewer during the majority of the follow- up interval. This, likewise, was a necessary consequence of limited personnel and financial resources. Since the interviewer was not blind with respect to the treatment group of each subject, one possible interpre~tion of results is that they could reflect a bias in favor of the experimental hypotheses due to either experimenter bias effects (Rosenthal, 1969) or to the subjects responding to subtle demand characteristics @me, 1969) of the interview situation


While there is no way to unequivocally eliminate such interpretations, nor to substantiate them, two issues deserve further consideration.

First, the evidence is not at all clear that conscientious experimenters subtly and uninten- tionally bias their results, and this contention has been seriously challenged by Barber and Silver (1968a,b). The use of multiple corroborating sources of information for each subject would tend to negate possible experimenter biases, as would the consistent checking of official hospital and jail incarceration records. Also, an explicit effort was made by the experimenters to obtain objective data. For instance, subjects were unaware of the drinking disposition coding categories used (see Method). An additional example of efforts made to provide objective data concerned the procedures used for dealing with subjects when they were found to be drunk or in other serious trouble at the time of a follow-up contact. It will be recalled from Table 2 that it was more often the case that control subjects were drunk than for experimental subjects. Thus, it was more likely that a control subject would be drunk at the time of follow-up contact, than for experimental subjects. While it would probably have been advantageous to the outcome results to simply record the dysfunction- ing days without offering assistance to the subject, it was decided that such a procedure would not be consistent with the professional ethics of research involving human subjects. Thus, when such occasions did occur, subjects were always apprised of local treatment resources and facilities available and encouraged to seek help. If the subject indicated a desire to take advantage of such services, an introductory telephone call to the treatment facility was made and it was arranged for the subject to receive services. As it evolved, more control subjects were informed of and made use of such treatment resources than did experimental subjects.

A second matter deserving consideration is the nature of follow-up information gathering procedures which would minimize the possibility of experimenter bias effects and demand characteristics occurring. The first possible alternative to consider is to be certain that the interviewer is naive to the experimental condition of the subjects. Beatty (1972), however, has pointed out that it is quite likely that a sophisticated observer in an experiment would become aware of the experimental hypotheses, even if not explicitly informed of that purpose. In a study such as the one reported here, the experimental treatment was so clearly different from conventional treatment, that it is highly probable that differences between subjects would be apparent to a relatively sophisticated observer within a single interview with a subject and his collaterals. Considering that the present study involved multiple contacts with both the subject and his collateral information sources, as well as frequent direct exposures to the subject’s behaviors, the possibility of a sophisticated observer’s naivety remaining intact is doubtful. One alternative, although extremely costly, would be to use a series of interviewers, each collecting data on each subject only one time. However, there is another critical aspect of collecting follow-up information which has not yet been ade- quately explored. This concerns the rapport which must be established and maintained with each subject and his collaterals in order to continue follow-up contact and tracing throughout an extended interval. Typically, follow-up studies of alcoholics produce only incomplete data and are frequently able to locate only about half or slightly more of the treated sample. In contrast, this report provides complete and detailed outcome information for 69 of the 70 total subjects, and subjects were tracked to distant and disparate geographic locations. It is most unlikely that this degree of intensity of data gathering would have been possible using one or more naive interviewers. Furthermore, it is hypothesized that those subjects who have poor records of functioning and limited social resources and relation- ships would be most difficult to track throughout the entire interval. Thus, the matter of

616 MARK B.SOBELL and LINDA C.SOBELL

developing sophisticated and valid procedures for obtaining complete follow-up data for as many subjects as possible is a highly complex problem and needs to be extensively investigated. Correspondingly, it should be investigated whether the mere conducting of follow-up may act as an effective after-care treatment for some subjects. Nonetheless, in the context of the follow-up techniques and measures presently available, it is submitted that the procedures and dependent variables used in this study are among the most intensive and objective which have ever been used.

Another problem in the interpretation of these results is related to the use of controlled drinking as a treatment goal for some patients. While this treatment goal was specifically intended for use only with certain patients, it was inevitable that other alcoholic patients in the hospital, including control subjects, were fully aware that controlled drinking was being experimentally investigated as a potentialfy attainable treatment outcome. Despite the fact that all control subjects were strongly and explicitly cautioned that without intensive training in a special treatment program they should never attempt to perform limited drinking on their own, there was no way of assuring that they would heed this caution. Therefore, it is conceivable that some subjects in experimental conditions other than controlled drinker experimental may have attempted to drink in a controlled manner after their discharge from the hospital. In the event that some subjects ignored the advice they had received and did attempt controlled drinking, it would be difficult to determine whether those instances were a direct result of exposure to the controlled drinking concept. In relation to this possibility, it should be recalled that one reason why controlled drinker control subjects were specifically assigned to that treatment goal was because they did not accept traditional dogma about the nature or treatment of alcoholism. One indication of the appropriateness of this assignment appears in the fohow-up results for the variable, use of therapeutic supports, which found controlled drinker control subjects to have rarely used traditional therapeutic supports during the follow-up interval. Further compounding the problem is the fact that subjects who were able to engage in controlled drinking for a significant (25 per cent) portion of the follow-up interval typically functioned considerably better throughout the interval than subjects who engaged in no controlled drinking days at all (see Table 3). Thus, while some subjects may possibty have attempted to perform controlled drinking, failed, and gone on to drink to excess, it does not necessarily directly follow that these subjects would have functioned better if they had attempted no controlled drinking at all. Again, it would be of great value to gather data describing the incidence of days of limited alcohol consumption among alcoholics who have been traditionally treated and relativeIy unaware of alternatives to abstinence. Such a study would have to include a sample of all individuals who were treated for alcoholism, regardless of treatment outcome, as it is typically the case that reports of successful outcomes are limited to include only those few cases where individuals are reported to have been totally abstinent since treatment.

In order to appropriately evaluate the findings of this study, it is essential to determine the duration of follow-up which is necessary for achieving stability of results. Gerard and Saenger (1966) have considered this question in depth, reviewing the findings of three long- term treatment outcome studies which differed in geographic locations, dependent variable measures, patient populations and methodologies (Davies et al., 1956; Gibbins and Armstrong, 1957; Gerard and Saenger, 1959). They concluded that for follow- up intervals of 1 yr duration or longer, “. . . the time interval does not influence the statistical patterning of the patients status at follow-up” (p. 101, 1966). Thus, while changes may occur in the status of individual patients, the number of patients in specific status categories at


any given time remains relatively constant. In extending their conclusion to this study, it is important to note that in one of the major studies they cited (Gerard and Saenger, 1959), controlled drinking was included as a category of follow-up status, with patients compared at 2, 5 and 8 yr after intake into a treatment program. The total follow-up interval to be used for final evaluation of this study will be 2 yr in length-twice the length of the follow-up interval determined by Gerard and Saenger to be adequate. Preliminary data already collected for subjects who have progressed well into their second post-discharge year appear to document the conclusion of Gerard and Saenger that a 1 yr interval is sufficient.

Various other analyses of post-discharge functioning, subject characteristics predictive of success for the different treatment goals, and experimental treatment components which were either effective or ineffective will be reported when complete 2 yr results are available. In addition to collecting data for all of the dependent variable measures reported for the 1st yr of follow-up, the second follow-up year will include a structured and recorded interview conducted with every subject at the end of his 2-yr post-discharge period. The interview includes questions asking the subject to evaluate various components of the experimental treatment and also to evaluate his own functioning throughout the follow-up interval.

While it will be at least 1 more yr before the results of this study can be evaluated and reported in more depth, there are at least three pertinent areas where intensive behavioral research is immediately needed: (1) definition and validation of operationally defined dependent variable measures of treatment outcome is of paramount importance-the validation of these measures should include baseline data documenting the measures’ stability for normal drinkers, as well as for non-treated (or conventionally treated) alcoholics; (2) procedures for gathering follow-up data without concern that results may reflect experimenter bias effects or demand characteristics should be developed if at all possible; and (3) the effect of frequent contact and interpersonal communication involved in performing follow-up should be investigated as an explicit after-care treatment modality (extended therapeutic supports) in its own right, as a number of subjects (including many control subjects) and their collaterals have remarked that they find the periodic contact to be of intense personal value for the subject.

In conclusion, while the results of this study appear to indicate a high degree of success, it is important to remember that statisticai significance in one study does not constitute gospel. The foundation of validating successful treatment lies in replication. The results of this experimental study will hopefully stimulate further efforts to apply behavioral technology to deal with drinking problems and to explore the efficacy of controlled drinking as a treatment goal.

REFERENCES

BARBER T. X. and SILVER M. J. (1968a) Fact, fiction, and the experimenter bias effect. Psychol. Bull. Monogr., 70 (Part 2), l-29.

BARBER T. X. and SILVER M. J. (1968b) Pitfalls in data analysis and interpretation: a reply to Rosenthal. Ps~chol. BUN. Monogr., 70 (Part 2), 48-62.

BEATTY W. W. (1972) How blind is blind? Psychol. Bull., 78, 70-71. BELASCO J. A. (1971) The criterion question revisited. BP. J. Addict., 66, 39-44. CRAWFORD J. J., CHALUWCY A. B. and HURLEY M. M. (1973) The evaluation of psychological approaches

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DAVIES D. L., SHEPARD M. and MYERS E. (1956) The 2-yr prognosis of 50 alcohol addicts after treatment in hospital. Q. JI. Stud. Alcohol, 17,485-502.


GERARD D. L. and SAENGER G. (1959) Interval between intake and follow-up as a factor in the evaluation of patients with a drinking problem. Q. JI. Stud. Alcohol, 20, 620-630.

GERARD D. L. and SAJZNGER G. (1966) Out-patient Treatment of Alcoholism. Toronto: University of Toronto Press.

G~BBINS R. J. and ARMSTRONG J. D. (1957) Effects of clinical treatment on behavior of alcoholic patients: an exploratory methodological investigation. Q. JI. Stud. Alcohol, l&429450.

HAYS W. L. (1963) Statistics for Psychologists. New York: Holt, Rinehart & Winston. JELLINEK E. M. (1960) The Disease Concept of Alcoholism. Hillhouse, New Haven. MCNEMAR Q. (1962) Psychological Statistics. John Wiley and Sons, New York. ORNE M. T. (1969) Demand characteristics and the concept of quasi-cont?ols. In Artifact in Behaviora

Research, (Eds. ROSENTHAL, R. and ROSNOW, R. L.), 143-179, Academic Press, New York. PATTISON E. M., HEADLEY E. B., GLESER G. C. and GOTTSCHALK L. A. (1968) Abstinence and normal

drinking: an assessment of changes in drinking patterns in alcoholics after treatment. Q. JI. Stud. Alcohol, 29, 610-633.

ROSENTHAL R. (1969) Interpersonal expectations: effects of the experimenter’s hypothesis. In Artifact in Behavioral Research (Eds. ROSENTHAL, R. and ROSNOW, R. L.): 181-277, Academic Press, New York.

SOBELL M. B. and SOBELL L. C. (1972) Individualized behavior therapy for alcoholics: rationale, procedures, preliminary results and appendix. Califarnia Mental Health Rekarch Monograph No. 13, Sacramento; Ca.

SOBELL, M. B. and SOBELL, L. C. (1973) Individualized behavior therapy for alcoholics. Behav. Therapy, 4, 49-72.

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Alcoholics treated by individualized behavior therapy: One year treatment outcome