rjehav. Res. & Therapy, 1972, Vol. IO, pp. 257 to 267. Perpa~non Press. Printed in England

DIFFERENCES IN BASELINE DRINKING BEHAVIOR BETWEEN ALCOHOLICS AND NORMAL DRINKERS*

MARK B. SoBELL?, HALMUTH H.SCHAEFERT and KENNETH C. MILLS#

Patton State Hospital, Patton, California, U.S.A.

(Received 6 January 1972)

Summary-Drink preference, sip magnitude, amount of time taken to consume drinks and amount of time between SIPS were measured for 23 normal drinkers and 26 hospital admitted alcoholics while they consumed up to 16 oz. of 86-proof liquor or its equivalent in an experimental bar-and-lounge environment. The alcoholics as defined in this study ordered more drinks, preferred straight drinks, took larger sips and drank faster, but took a longer time between sips than did the normal drinkers. The utility of baseline drinking measures and the external validity of the results are discussed.

IN RECENT years, behavior modification techniques have become well accepted as methods of therapy for neurosis, psychosis and character disorders (Schaefer and Martin, 1969; Bandura, 1969; Franks, 1969). Basic to these techniques is a knowledge of differences be- tween the patient’s behavior and the limits within which the community considers a given behavior to be socially acceptable, as the development of most behavior modification designs must begin with a precise definition of the target behavior involved. Data describing these differences may be obtained through the use of behavioral baseline measures of frequency, magnitude, or some other dimension of a behavior, in the absence of experimental manipulations. Once baseline measures have been obtained, experimental treatments may be introduced and changes in target behaviors analyzed.

The potential utility of behavioral baseline measures as a research tool for the study of alcoholism is large. Yet, to this time, most studies of drinking patterns available in the literature are either of a survey questionnaire variety (Cahalan and Cisin, 1968a; Cahalan and Cisin, 1968b) or concern personality characteristic correlates (Sutherland et al., 1950; Syme, 19.57). A number of studies conducted over the past few years have had an experi- mental basis (Mendelson and LaDou, 1964; Mendelson et al., 1964; McNamee et al., 1969; Tamerin and Mendelson, 1969). In these experiments intoxication was induced in volunteer alcoholic patients over extended periods of time, sometimes as long as 3 weeks, and the dependent variables measured were usually physiological or clinical rather than behavioral.

‘B This investigation was supported (in part) by Public Health Service Grant No. 1 RO 1 MH 16547-02 and California Department of Mental Hygiene Grant No. RP-69-11-15. The opinions or conclusions stated in this paper are those of the authors and are not to be construed as official or as necessarily reflecting the policy of the Department of Mental Hygiene.

t Now with: Alcoholism Services, Orange County Department of Mental Health, 9842 West 13th St., Santa Ana, California, U.S.A., 92703. Requests for reprints should be mailed to that address.

: Now with: Department of Psychology, University of Auckland, Auckland, New Zealand.

9 Now with: Division of Research, Department of Motor Vehicles, Olympia, Washington, 98501, U.S.A.

257

258 AIARK B.soBa~, H~L~IuT~I tt..sc~Awm and KENNETH c. lm.Ls

Nathan and O’Brien (1971) performed a study where drinking patterns of four alcoholic and four matched non-alcoholic subjects were recorded over a period of 18 days. While no quantitative data were reported for specific drinking behavior, they concluded that there were striking parallels between skid-row type alcoholic drinking which they had studied previously and the alcoholic drinking patterns they observed in Co. In another study, Schaefer et al. (1971) compared specific drinking behavior of 16 alcoholics and 15 normal drinkers. They found that alcoholics as compared to normal drinkers preferred straight to mixed drinks and took much larger sips of their drinks. Temporal variables were not rcpor- ted, however, and the use of a &drink limit for all subjects did not illuminate differences between groups in terms of total amount of alcohol consumed.

The experiment reported in this paper investigates a number of behavioral variables basic to and immediately related with the act of becoming drunk. Such detailed behavioral measures of the early stages of intoxication are prerequisite to the development of effective modes of behavior therapy, regardless of whether the therapeutic goal is to train chronic alcoholics to abstain from alcohol or to become controlled drinkers. As summarized by Pattison (1966) there are numerous reports in the literature documenting normal drinking by former alcoholics, in spite of the fact that the treatment procedures used specifically discouraged such behavior. More recently, controlled drinking, attained by modifying those aspects of the alcoholics’ responses which diRer from normal drinking, has been demonstrated to be a feasible and effective treatment goai for some alcoholics (Sobell and Sobell, 1972a, 1972b).

METHOD

Twenty-six voluntary male alcoholic patients temporarily residing on an alcoholism treatment unit within Patton State Hospital volunteered to serve as Ss for the experiment. In addition, 23 male normal drinkers from the surrounding community were also recruited to serve. The alcoholic Ss all had a history of chronic alcoholism and a mean of 5.8 previous admissions to treatment institutions for this explicit problem. Additionally, all had ex- perienced some withdrawal symptoms from alcohol at least once. These symptoms ranged in severity from shakes and convulsions to delirium tremens. All of the alcoholic Ss had consumed no alcohol for at least 3 weeks prior to the study. They were cleared for parti- cipation by the unit psychiatrist and showed no evidence of severely disturbed liver function, chronic brain syndrome, sub-normal intelligence or drug addiction. None of the patients used medication concurrent with the study and none had a history of serious physical assaultive behavior while sober or drunk. Each of the normal drinkers had never experienced any disruption of normal activities due to excessive use of alcoholic beverages.

The alcoholics had a mean age of 38.69 years with a range from 24 to 54 years while the normal drinkers ranged from 21 to 53 years of age with a mean of 29.78 years. This difference was statistically significant (t = 3.80; cff= 47; p < 0.001). Another statistically significant difference between the two groups was education level. Alcoholics had a mean education of 11.34 years with a range from 8 to 16 years. This was significantly different from the normal drinkers who had a mean education of 15.37 years and a range from 12 to I8 years (t=6.56; df=47; p<O.OOl). For both groups, public bars were among the control stimuli for drinking.

Ptoceduue The Ss attended separate drinking sessions in an experimental bar and cocktail lounge

DIFFERENCES IN BASELINE DRINKING BEHAVIOR 259

located on an alcoholism treatment unit at Patton State Hospital. The simulated bar setting was quite realistic and included a padded and varnished half-moon bar, padded bar stools, several tables and chairs, dim lighting, a full-length mirror behind the bar complete with a glass and bottle display, and piped-in music. The alcoholic beverages served included well-known brands of hard liquors, wines and beers which had been confiscated by the Alcoholic Beverage Control Board of the State of California and made available for research purposes. The bartender during most of the sessions was one of the patients residing on the unit whose vocation was bartending.

Alcoholic Ss as well as normal drinker Ss were usually studied in groups of three. At the beginning of a session, Ss were instructed that they could drink anything they wanted with the exception that they could have no more than 16 oz. of 86-proof liquor or its equivalent in alcohol content. For instance, 12 oz. of beer (slightly less than 4 per cent alcohol content) were considered the equivalent of 1 oz. of 86-proof liquor. A mixed drink consisted of I oz. of liquor combined with 2 oz. of mixer. To facilitate data collection, no doubles were served, although Ss could be served two drinks simultaneously. All intoxicated normal drinkers were driven home by staff members. The sole reason for deci- ding on a 16-02. limit rather than unlimited drinking was a concern for the safety of the patients as the blood alcohol levels which would result from consuming more than 16 oz. within a short period of time might constitute a medical risk.

Research personnel were in the bar during all sessions and drank non-alcoholic bever- ages while recording data. Staff members were instructed to be generally friendly in social interactions with the Ss but to concentrate on the collection of data. This posture was neces- sary in order to assure competent recording of data while maintaining a realistic bar atmo- sphere. For each drink ordered, the type of drink, number of sips to consume it, time taken to consume the drink and the time between each sip was recorded on a data sheet. Stop- watches, wrist watches and occasionaily a wall clock with a sweep second hand were used to record temporal data. Each sessicn lasted a maximum of 4 hr. In almost all cases Ss had stopped ordering before the time expired.

Consumption limit RESULTS

Alcoholic Ss ordered a mean of 15.27 total drinks and only rarely refused any of the possible 16 drinks. This is not to say that 16 oz. of liquor did not have an inebriating effect on those Ss. Most of them were quite un-coordinated in their motor behavior, had slurred speech and ended up sleeping the rest of the day. Many also experienced severe hangovers and bouts of vomiting. Normal drinkers, on the other hand, ordered a mean of only 6.65 drinks each, and only one of the 23 Ss in that group ordered more than 12 drinks. These results occurred even though the drinks were free and transportation home was provided. A t test on the difference between the mean number of drinks ordered by Ss in each group was found significant (t = 12.37; @= 47; p < 0.001).

Drink preference Alcoholic Ss had a significant preference for straight drinks which composed 54 per cent

of all drinks they ordered as opposed to 18 per cent of all drinks ordered by the normal drinkers. On the other hand, 63 per cent of all drinks ordered by the normal drinkers were mixed drinks and an additional 19 per cent were beer. The respective totals for alcoholics were 32 per cent mixed drinks and 14 per cent beer. A t test comparing individual S pro-

260 MARK B. SOBELL, HALMUTH H. SCHAEFER and KENNETH c. MILLS

portions of straight drinks ordered between the two groups was significant (t-3.53; df=47, /1<0.001).

Sip magnitude

With sip size as the dependent measure, it was found that no matter what type of alcoholic beverage was ordered, alcoholic Ss typically took approximately two to three times as much liquid per sip as did the normal drinkers. Alcoholic Ss, for example, con- sumed a mean of 0.72 oz. per sip for straight drinks while normal drinker Ss had a mean sip magnitude of 0.36 oz. per sip. The largest difference occurred when Ss from the two groups ordered mixed drinks. The alcoholic Ss consumed a mean of about 1.25 oz. of mixed drink per sip, whereas the normal drinker Ss consumed a mean of only 0.39 oz. per sip for a drink of the same size and strength. Thus, even if alcoholic Ss did order the same type of drink (mixed) which most of the normal drinker Ss preferred, the similarity between the two persons ended there as the alcoholics had a much different manner of consuming those drinks. Alcoholic Ss, for instance, usually consumed the same drink in from two to three sips which it took normal drinker Ss approximately nine sips to finish. A t test comparing the difference between alcoholics and normal drinkers for mean number of ounces per sip of drink for all drinks combined showed the difference to be statistically significant (t=3.74; df=47; p<O.OOl).

A more detailed analysis of sip magnitude appears in Fig. 1 which displays the mean number of oz. per sip for each group as a function of type of drink and drink number. There is a great similarity in the general shape and flatness of the two curves in Fig. l(A). The other parts of the figure demonstrate that this same difference and lack of trend was main- tained when straight drinks and mixed drinks were each analyzed separately. It must be kept in mind that data for the normal drinkers following drink number 12 represents only one S and should not be taken as in any way indicative of a group performance. From drink 1 through drink 12, for example, the curve for normal drinkers in Fig. 2(B) is quite stable. Only for beer was there a difference over and above that of alcoholic Ss simply taking larger sips than normal drinker Ss. In Fig. 2(D) it is shown that alcoholic Ss who ordered beers late in a session took increasingly larger quantities of beer per sip. This trend was opposite to that exhibited by normal drinker Ss.

Time per drink

A clear and highly significant difference between groups in time per drink was found with normal drinker Ss typically taking from two to three times longer to consume a drink than alcoholic Ss. This difference was sustained no matter whether the drink in question was a straight drink, a mixed drink or beer. Normal drinker Ss took an average (mean of individual S medians) of 1720 set to consume a straight drink while alcoholic Ss typically consumed the same drink in 660 sec. If the drink was mixed, normal drinker Ss took a mean of 1550 set to finish as opposed to 590 set for alcoholic Ss. Finally, normal drinker Ss consumed a beer in an average of 1907 set compared to only 761 set for alcoholic SS.

A t test performed on the difference between the means of the individual S’s median time per drink for all drinks combined showed this difference to be statistically significant (t=6.22; df=47; p<O.OOl).

Figure 2 shows a breakdown of the time per drink data as a function of drink number. In Fig. 2(A-D) a trend toward unity is seen. This is especially so when the data for the one normal drinker finishing more than 12 oz. is eliminated from the normal drinker sample. A very likely explanation for the apparent trend toward unity was that the merging of the

DIFFERENCES IN BASELINE DRINKING BEHAVIOR 261

Al 3 6) STRAIGHT DRINKS

1 ALL !‘HINKS

1 ____ _scctal dr,nkr,s

2 alcoholics

Dl MIXED DRINKS

2’ 4’ 6’ 8’ ld 12’ 14’ 161 2’ 4’ 6’ 8’ ld 12’ 14’ 16’

,’ .

DRINK NUMBER

FIG. 1. Mean sip magnitude measured by ounces per sip for alcoholics (N=26) and normal drinkers (N=23) as a function of drink number and type of drink ordered. Dotted lines

indicate N= 1.

curves was an artifact which resulted because the data for later drink numbers represented only a selective sample of normal drinkers. To investigate this hypothesis, a detailed exami- nation of individual normal drinker temporal patterns was performed. It was found that I2 of the Ss showed a pattern of taking a longer time between drinks as drinking progressed, while eight Ss drank increasingly faster over consecutive drinks. The remaining three Ss showed no clear temporal pattern. Since the 12 Ss who slowed down consumed a mean of 6.67 drinks each and the eight Ss who drank increasingly rapidly consumed a mean of only 5.80 drinks per S, it appears that the data displayed in Fig. 2(A-D) are not an artifact of selection but are representative of the entire sample of normal drinkers.

Time between sips For all analyses of sip intervals, individual medians were first computed for each drink

taken by each S. The mean of these medians was then used as the most representative group sip interresponse time. This analysis was used because there were occasional extremely long durations of sip intervals for most Ss. The usual cause of such erratic intervals was either that the S became deeply engrossed in a conversation away from his drink, or that he had momentarily retired to the restroom. The use of individual S medians avoided con- tamination of the data by these exceptions.

Surprisingly, alcoholic Ss generally took a longer time between sips than did normal drinker Ss. If the drink ordered was a straight drink, the overwhelming preference of alcoholic Ss, normal drinker Ss had a mean intersip time of 216 set compared to 387 set for alcoholic Ss. This difference is not maintained if intersip times are considered for mixed

262 ~~AKK n. SOBELL, HALMUT'H H. SCHAEFEI~ and KENNETH c. MILLS

drinks. Alcoholic Ss had a mean intersip time of 160 set for mixed drinks compared to 163 set for normal drinker Ss. The difference reappears, however, when only beer is considered with alcoholic Ss having a mean intersip time of 206 set and normal drinker Ss a mean intersip time of 136 sec. The difference in mean sip interval between the two groups for all drinks combined was subjected to a t test and found to be statistically signifi- hcant (t=2.67; cff=47; ~~0.02).

MIXED DRINKS

3o01 I

1 !4 5’8 932 l&6

Al

3 STRAIGHT DlllNb:

_____.soc~al drlnkerr

-alcoholics

D) - \ BEER

\

I 1 1-4 5% 9112 13%

NUMBER

FIG. 2. Mean time (xc) per drink as a function of drink number and type of drink ordered for alcoholics (N=26) and normal drinkers (N=23). Means were computed from individual

subject medians. Dotted lines indicate N= 1.

The apparent reversal of overall sip interval data which occurred when the drink order- ed was a mixed drink seems to reflect the fact that all alcoholic Ss ordering mixed drinks showed an increase in sip interval as a function of drink number. This same trend, for the alcoholic Ss to accelerate their sipping until they simply stopped drinking is shown in Fig. 3 where mean time between sips is considered as a function of drink number and type of drink. A detailed examination of the raw data once again showed that it was unlikely the results were an artifact of selection of Ss at larger numbers of drinks.

Reliability qf measures While circumstances made it impractical to obtain an immediate replication of the nor-

mal drinker results from the original Ss, such a replication was possible for the data of alcoholic Ss. All of the alcoholic Ss participated in a second drinking session which was conducted 2 days after the initial session. The results were almost identical for the two sessions. For instance, where the alcoholic Ss had ordered a mean of 15.27 total drinks

DIFFERENCES IN BASELINE DRINKING BEHAVIOR 263

A) ALL DRINKS B) STRAIGHT DRINKS

MIXED DRINKS 1

BEER

DRINK NUMBER

FIG. 3. Mean time (set) between sips as a function of drink number and type of drink ordered for alcoholics (N=26) and normal drinkers (N=23). Dotted lines indicate N= 1.

per man during the first session, the same Ss ordered a mean of 15.86 total drinks each in the second session. In addition to this, further measures such as the mean number of ounces per sip and type of drinks ordered also bore a striking similarity to the first session results. Examples of this consistency appear in Figs. 4 and 5 which show, respectively, mean time per drink and mean time between sips as a function of drink number and session number. The most impressive replication occurred for time between sips. The mean intersip time during session two was 288 set, only slightly different from the 295 set value recorded for session one.

DISCUSSION

From the results of this experiment and a previous study (Schaefer, Sobell and Mills, 1970) it is now possible to describe general profiles of drinking behavior within our con- trolled environment for alcoholics and normal drinkers. These profiles are shown in Table 1.

All of the statements in the profiies in Table 1 are purposely worded so that the com- parisons made are relative. They are not absolute predictors of behavior outside of that environment. The experimental bar is in some ways, of course, a somewhat unnatural setting in which to drink: it is located on an alcoho~sm treatment unit of a hospital and all drinks served are free. The problems of generalization encountered in attempting to apply the results of data recorded in the experimental bar, however, pale in comparison to the factors involved in attempting to structure a strictly naturalistic experiment.

264 MARK R. SOBELL, F~ALMIJTH H. SCHAEFER and KENNETH c. MILLS

;; 9 800-

0 : '" 700-

z

E 600-

: a

iz- 500- F

z I 400-

. , \

//’ ‘\\ / i’ ‘\\

/ ‘\ F /

/’ /’

/

/

.session 1

,____.session 2

DRINK NUMBER

FIG. 4. Mean time (set) per drmk as a function of drink number and session number for alcoholics (N=26). Means were computed from individual subject medians.

400

300

200 I

DRINK NV MBE R

FIG. 5. Mean time (set) between sips as a function of drink number and session number for alcoholics (N=26). Means were computed from individual subject medians.

TABLE 1. BEHAVIORALPROF~LESOFALCOHOLICSANDNORMALDRINKERS

Alcoholic

1. Will almost always drink more than 12 drinks within a 4-hr period.

2. Generally orders straight drinks. 3. Takes a larger size sip, no matter what

type of drink. 4. Drinks much faster than a normal

drinker; sometimes three times as fast. 5. Sips more slowly than normal drinkers,

but larger mouthful per sip.

Normal drinker

1. Very seldom drinks more than 12 drinks within a 4-hr period.

2. Typically orders mixed drinks. 3. Takes a smaller size sip, no matter what

type of drink. 4. Drinks considerably slower than an

alcoholic. 5. Takes many rapid and small sips.

DIFFERENCES IN BASELINE DRINKING BEHAVIOR 265

To evaluate the external validity of the results of these experiments, one could attempt to conduct research in a real bar in the community. The problems posed by such a design, however, are overwhelming. Problems of uncontrolled variables include for instance:

(1) Strength and size of drinks served in commercial establishments are not standard- ized. In a simulated bar, such variables are held constant as a matter of routine.

(2) How does one validly determine whether a S is just beginning his drinking with the drinks he orders or whether he is in the process of making the rounds of his favorite bars? This is especially important if one is interested in studying alcoholics in the beginning stages of intoxication, not continued drinking once intoxicated. Further,

just because a person has finished drinking at one bar, this does not necessarily mean that he has finished drinking altogether, as many persons do their drinking in a number of environments successively. Also, normal drinker Ss who can order free drinks in a simulated bar might be expected to do the bulk of their drinking there.

(3) At a commercial establishment persons have to pay for their drinks. Persons low on cash could be expected to buy their favorite beverage at a liquor store and drink it at home.

These are only a few of the tremendous number of confounding variables to be reckoned with in conducting experiments in public bars without a rigorous structuring of the situation.

Instead, one might more fruitfully consider which of the results produced in a simulated bar setting might change in a real setting and what the character of these changes might be. A first factor to be considered is that the alcoholic Ss were incarcerated while the normal drinker Ss were not. This might be expected to cause the alcoholic Ss to draw out their drinking, i.e. make their drinks last, because no more liquor was available after the con- clusion of the session. This effect, however, would serve only to exaggerate differences already present in the data.

In a naturalistic setting normal drinkers might also be expected to order fewer drinks when they have to pay for them. But this would probably be true for alcoholics as well, as they might well use their available funds more efficiently by buying a bottle. Once again,

the probable effect would tend only to exaggerate already present differences between alco- holic and normal drinker Ss.

There are many important applications of the results of these studies which can be pur- sued. For one thing, it is clear that an operational definition of alcoholism based on obser- vable drinking behaviors is possible. To be sure, the specific behaviors recorded here are by no means the only ones which require exploration. Likewise, drinking and other behavior should be obtained for a variety of alcoholic S populations. It may very well be that a variety of separate alcoholic drinking patterns can be found. Such drinking patterns would

be likely to correlate with variables such as whether the person is a steady or binge drinker, personality test results such as the MMPI, and whether the person drinks in bars or is a solitary drinker.

The relevance of these results to behavior modification techniques in general needs little explication here. A behavior therapist must know which behavior needs changing before ever attempting to put changes into effect. For example, efforts to shape normal drinking behaviors in alcoholic Ss by training them to wait progressively longer between sips of a drink could be expected to be ineffective. Results from the present experiment show that alcoholics already do sip more slowly than normal drinkers. Efforts toward decreas- ing the magnitude of sip size, on the other hand, are likely to prove fruitful.

266 MARK B. SOBELL,HALMUTH H. SCHAEFER and KENNETH c. MILLS

Along this same line of thought there is much opportunity to attempt to train alcoholics to become controlled drinkers as an alternative to abstinence. Various operant conditioning principles provide easy tools for shaping the desired behavior (making the alcoholic pattern more like the normal drinker’s), an approach to the problem of alcoholism which has been neglected. While it is true that the usual problems of generalization to the environment outside of an experimental setting arise here, the same problem exists for all types of therapy currently used to treat alcoholism. A first attempt using this approach by Mills et al. (1971) found that avoidance conditioning techniques worked successfully to shape the acquisition of a socially acceptable drinking response repertoire over as few as 12 conditioning sessions. A more extensive and comprehensive behavioral treatment program for alcoholics has been used by Sobell and Sobell (1972a, 1972b). In that study, avoidance conditioning to shape appropriate drinking behavior was combined with procedures to analyze setting events for the drinking of individual Ss, and to train those Ss in alternative, more appro- priate responses to those situations. The results of preliminary follow-up investigations for the latter study look extremely promising.

A final application of baseline results which has broad implications is their use as a preventive measure. It might be possible, given a large enough statistical sample of alcoholic and normal drinking behavior, to determine whether a given person’s drinking pattern falls within one or the other norm, or whether it is at some transition stage. This would be especially valuable if longitudinal measures of developing alcoholics could be obtained. One could expect that it would be a less difficult change for the person in transi- tion from normal drinker to alcoholic to halt this transition than to terminate full alcoholic drinking.

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DIFFERENCES IN BASELINE DRINKINCi BEHAVIOR 267

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