Predicting relapse and recovery in alcoholism and addiction: Neuropsychology, personality, and cognitive style

Journal of Substance Abuse Treatment, Vol. 8, pp. 277-291, 1991 Printed in the USA. All rights reserved.

0740-5472/91 $3.00 + .OO Copyright 0 1991 Pergamon Press plc

INTEGRATIVE REVIEW

Predicting Relapse and Recovery in Alcoholism and Addiction:

Neuropsychology, Personality, and Cognitive Style

LAURENCE MILLER, PhD

Private Practice, Boca Raton, Florida

Abstract - Neuropsychological studies of substance abuse treatment outcome have generally found successful recoverers to show intact functioning on most measures, whereas relapsers do poorly on tests of language, abstract reasoning, planning, and cognitive flexibility. These have been related to involvement of left hemisphere and frontal lobe functions. Personality profiles of successful remitters, with or without formal treatment, include future goal-orientation, fnrstration-tolerance, and self-efficacy, while relapsers are characterized by impulsivity, antisocial personality, and affective disorders. It is proposed that what these neuropsychological and personality indexes are actually describing in successful recoverers is the neuropsychodynamic trait variable of ego autonomy, which is related to a reflective, nonimpulsive, goal-directed cognitive style. Implications of the neuropsychodynamic model for the evaluation and treatment of substance abusers is discussed.

Keywords-alcoholism; addiction; neuropsychology; cognitive style; ego autonomy.

INTRODUCTION

INTHEE~~~ICTTODEVELOP andimplementmoreclin- ically sound and cost-efficient forms of substance abuse treatment, attention has generally focused on the nature of the various treatment techniques, processes, and programs themselves. This has been to the relative neglect of important subject variables-characteristics of the clients or patients- that may influence recovery and relapse. In part, such a lopsided emphasis has been due to the prevailing conceptualization of alcoholism and drug abuse as a unitary syn- dromic monolith, a view which fails to take into account important individual differences in intellectual, tempermental, cognitive, and neuropsychological variables-what we might call differences in personality and cognitive style- that may dramatically affect recovery and relapse.

Previous reviews of the neuropsychology and neuropsychodynamics of alcoholism and addiction (Miller, 1985, 199Oa) have reported impairment in abstract con-

Requests for reprints should be addressed to Laurence Miller, PLD.

Plaza Four, Suite 101,399 W. Camino Gardens Blvd., Boca Raton, FL 33432.

cept formation, set-formation, set-maintenance and set-shifting, behavioral self-modulation, and cognitive flexibility. Also, deficits in verbal skills and language functioning have been found in alcoholics and in their as-yet nondrinking offspring. Personality studies of alcoholics and drug abusers have emphasized such traits as field dependency, external locus of control, atten- uated time extension, poor ego strength, and disturbed object relations. The psychopathology of the most dysfunctional types of alcoholics and drug abusers seems to be dominated by impulsive character disorder and antisocial personality, although there also appears to be a subgroup of anxious, depressed substance abusers (Cloninger, 1987; Cloninger, Christiansen, Reich, & Gottesman, 1978; Miller, 1987, 1988, 1990b, in press; Rounsaville & Kleber, 1986; Schuckit, 1986).

In an earlier paper (Miller, 199Oa), I proposed that the neuropsychological and personality variables contributing to the addictions may be conceptualized in terms of Klein’s (1954) and Shapiro’s (1965) concept of cognitive style, the individual pattern of intellectual, perceptual, and interpretive processes which af- fects how a given person views the world and regulates his or her behavior in it. The majority of chronic, dysfunctional alcoholics and addicts seem to be character-

277

278 L. Miller

ized by a nonreflective, impulsive cognitive style that relates to an inability to use inner speech and other verbal self-regulatory mechanisms to evaluate, plan, and guide behavior (Miller, 1987, 1988, 1989a, 1990b).

Many traditional neuropsychological accounts of impulsivity and substance abuse have made reference to localized deficits in left-hemisphere and/or frontal lobe mechanisms. Alternatively, I suggested that many of the findings on “neuropsychological” testing of alcoholics and drug abusers may be interpreted as reflecting a preexisting, constitutional cognitive style pattern, rather than, or at least in addition to, any acquired “brain damage” or “lesions” due to substance use or other causes (Miller, 1986, 1989b). Further, this cognitive style may also underlie the relative lack of ego-autonomy (Hartmann, 1939) or self-efficacy (Bandura, 1977, 1982) seen in many chronic substance abusers (Miller, 1990b, 1991, in press).

While useful for the purposes of research, clinical assessment and theoretical model building, it may be questioned whether this neuropsychodynamic approach to the addictions can help explain why some abusers get better, with or without treatment, and some seem not to ever recover, no matter what kind of interventions are tried. The ultimate test of theoretical utility will be the application of a model to the design and implementation of more effective intervention strategies. This paper will examine the relative roles of neuropsychology, personality, and cognitive style as influencing and determining processes in relapse and recovery, as well as the implications for treatment or other disposition of substance abusers.

The present paper is intended neither as a method- ological review nor as a metaanalytic study, but will instead focus on the substantive issues related to substance abuse outcome. Readers are encouraged to re- fer to the primary sources for details of study design, populations, and measures. As most studies in this area have dealt with alcohol abuse, the content of this review will reflect that predominance.

NEUROPSYCHOLOGICAL PREDICTORS OF TREATMENT OUTCOME

Gregson & Taylor (1977) studied a sample of male alcoholics in New Zealand with a specially designed Pat- terned Cognitive Impairment Test (PCIT) that assesses mainly memory and mental classification skills. Also administered were the Triangular Mazes and a verbal short form of the WAIS. The best predictor of relative relapse rates was found to be a derived measure that the authors termed relative cognitive efficiency. Those higher in this trait were found to have lower relapse rates. The number of previous hospitalizations was virtually useless as a predictor of future relapse, suggesting that the amount of full-time treatment a pa-

tient is exposed to has little bearing per se on whether he or she resumes problem drinking.

Interestingly, there was a relationship between having active religious beliefs and joining Alcoholics Anonymous (AA), and between joining AA and staying abstinent. But, on average, those expatients who stayed abstinent without joining AA were found to have a higher level of cognitive efficiency. On the other hand, the worst prognosis seemed to be for subjects with low cognitive efficiency, little or no religious beliefs, and who did not join AA. The implication seems to be that high cognitive efficiency may medi- ate success in self-efforts at sobriety, but, lacking this trait, the external encouragement and affiliative control exerted by AA-type support groups may serve as an alternative means of staying sober.

Given the strength of the relationship found between cognitive efficiency and relative abstinence and relapse rates found in the above study, Abbot & Greg- son (1981) studied another group of alcoholics with the PCIT and also included the Rod-and-Frame Test, which has been reported to measure field dependency (the tendency to be influenced by cues from the external environment, rather than by internal perception, interpretation, and judgment) and short-term memory for visuospatial material. The major finding was an association between cognitive dysfunction and poor treatment outcome, supporting the view that cognitive functioning plays a significant role in mediating relapse. In this study, PCIT scores were not found to be significant predictors, probably because few of the alcoholics in the present study had scores indicative of severe impairment (the threshold, or restriction-of- range effect). One of the best predictors of posttreatment status, as in the earlier Gregson & Taylor (1977) study, was occupational status. Also significantly predictive were educational level, highest occupation at- tained, previous social functioning, locus of control (LOC; whether one perceives events as self-influenced or externally-controlled), and self-rating of the severity of their drinking problems.

A study by Donovan, Kivlahan, & Walker (1984) sought to investigate a number of factors that might influence the relationship between neuropsychological impairment and treatment outcome in alcoholics. Age was found to be a major predictor of neuropsychological performance, alcoholics over 50 doing more poorly than younger subjects, while length of abstinence had no effect on cognitive functioning. This suggests that, once detoxification has occurred and withdrawal effects have subsided, older patients might require more assistance with the adjustment to treatment, regardless of prior drinking chronicity or re- cency of last drink.

In this study, neuropsychological variables had a relatively limited value in predicting later drinking be-

Predicting Relapse and Recovery in Alcoholism and Addiction 279

havior. Block Design was the only measure that was significantly related to drinking status at the 6-month follow-up, with those subjects classified as treatment successes having higher pretreatment scores than relapsers. As in Abbot & Gregson’s (1981) study, this may be due to threshold effects, as there were few severely impaired neuropsychological profiles among these subjects. Neuropsychological measures were, however, predictive of employment status, with those individuals working full-time at follow-up having con- sistently better neuropsychological performance profiles, both at pretest and retest, than those who were working only part-time or were unemployed. Simi- larly, neuropsychological function was predictive of the amount of time spent working at the nine-month follow-up.

Leber, Parsons, and Nichols (1985) investigated the relationship of neuropsychological functioning to clinical ratings of participation in therapeutic activities and prediction of posttreatment outcome in two groups of alcoholic men. A clear finding was that the lower the ratings of clinical progress in therapy, the poorer the performance on neuropsychological testing. This suggests that the cognitive abilities measured by the tests have some degree of similarity to the cognitive abilities required for effective participation in therapy.

Specifically, clinicians’ judgments of their patients’ ability to use analogies and ability to generalize from one situation to another were related to the patients’ performance on the Wisconsin Card Sorting Test (WCST), a measure of cognitive flexibility, on the Shipley Conceptual Quotient Scale, which assesses verbal abstraction abilities, and on the Shipley Men- tal Age scale. Nonverbal neuropsychological abilities were also related to other dimensions of clinical improvement and to general interpersonal functioning. In addition, LOC Chance scores appeared to be related to prognosis, in that patients who were likely to see events as being controlled by random forces outside themselves were judged to have poorer prognoses. Other studies (Shelton, Parsons, Leber, & Yohman, 1982) have also found that high LOC Chance scores tend to be related to poor performance on neuropsychological tests. The authors of the present study speculate that patients with neuropsychological deficits may see events as being controlled by outside forces because their own adaptive cognitive abilities are impaired.

Kupke & O’Brien (1985) investigated the generaliz- ability of neuropsychological test data to behavioral problems and limitations exhibited by alcoholics within an inpatient treatment program. Ratings sup- plied by alcohol counselors of problematic behaviors were used to form two groups representing behaviorally.impaired and behaviorally unimpaired alcoholics. The behaviorally impaired subjects were found to

have significantly longer histories of alcoholism, a greater number of abnormalities on neurologic exam- ination, a higher incidence of suboptimal nutrition, and poorer neuropsychological functioning. This impairment was greatest on tests measuring psychomo- tor speed, problem solving, tactual-motor integration, elementary reasoning, memory, and visuospatial analysis and synthesis.

A neuropsychological predictor study involving opiate addicts was carried out by Chastian, Lehman, and Joe (1986). They used an estimate of intellectual efficiency to study a large, demographically partialled group of former opioid abusers from the 1Zyear follow-up study of the Drug Abuse Reporting Pro- gram (DARP). Results showed that addicts with higher estimated IQs tended to have had a longer period of remission, had not used daily in the year pre- ceding the 12-year follow-up, had shorter overall addiction careers, and had quit opioid use for reasons other than the unavailability or poor quality of drugs. These results suggest that more intelligent addicts are more likely to eventually get off drugs, to have better jobs, and to go back to school.

Interestingly, addicts with higher levels of intelligence were found to have greater family conflict and higher levels of dissatisfaction with their current life situation. Although, this could hypothetically lead to drug experimentation and addiction, the length of addiction may be shorter for these subjects since they tend to have greater cognitive coping resources. Since addicts with lower levels of intellectual functioning seem to have less family turmoil and more satisfaction with self and life, the investigators suggest that perhaps more thought should be given to family dynam- ics and its role in addiction. If the addict has greater resources to leave the addict lifestyle, then the career length may be shorter. Alternatively, we might consider that offspring with low-IQ, low-skill, and low- aspiration might have less conflict with parents and family members of similarly low-IQ, skill, and aspiration, whereas those with higher intellect, skills, and aspirations than their family members might “rebel” in a more adaptive direction.

Parsons (1987) has described a research program designed specifically to examine the relationship of neuropsychological functioning to alcoholism treatment outcome. These studies have found that subjects who resumed drinking after treatment had lower scores on the neuropsychological measures at both initial testing and retesting, compared to subjects who remained abstinent. This suggests that the resumers may have been somewhat more neuropsychologically impaired to begin with. Relative to resumers, the cognitive functioning of the abstainers appeared to improve over time to nearly normal levels, although some areas of residual deficit remained.

L. Miller

The subject group was next divided into those who were rated as clearly having a good prognosis and those with a poor prognosis-approximately the upper and lower quarters of the sample. There were no differences between the groups in age or education, but the poor- prognosis group had a significantly longer drinking history than the good-prognosis group. Neuropsycho- logically, the poor-prognosis subjects did significantly worse on measures of abstraction, problem-solving, and perceptual-motor skills. They also had poorer verbal skills, short-term visual memory, visuospatial paired-associate learning, visuospatial analytic skills, and perceptual-motor set-shifting, and they showed greater perseveration. Thus, in this sample, neuropsychological test performance was predictive of therapists’ ratings, particularly ratings of prognosis.

Based on these findings, which suggested impaired problem-solving abilities in poor-prognosis alcoholics, a second study administered three tests believed to be particularly sensitive to problem-solving abilities, and subjects were rated as high or low on these measures. In all significant comparisons, the high group was rated better on a number of indices assessing the outcome success of the treatment program. On measures of treatment behavior, the high performers on the problem-solving test did better on scores of insight, orientation toward the future, and therapeutic benefit, but not on group participation, involvement in therapy, motivation, or approach toward change. In terms of cognitive functioning during treatment, high problem-solvers did better on analogical reasoning and ability to learn. On a scale predicting treatment outcome at one year, high problem-solvers were supe- rior in terms of drinking behavior, vocational status, cognitive functioning, and overall quality of life.

Given these results, it would appear that the problem- solving behavior of alcoholics, as measured by neuropsychological tests, is positively related to treatment behavior, cognitive functioning during therapy, and outcome as rated by therapists. A third study in the research program described by Parsons (1987) sought to determine more precisely what aspects of cognitive functioning are most relevant to treatment outcome prediction. Data analysis revealed that tests involving verbal reasoning and linguistic skills were the best predictors of therapists’ ratings. Correlations with the remaining nonverbal tests were largely nonsignificant. Further, traditional clinical measures such as the Beck Depression Inventory and the State Anxiety Inventory were unrelated to therapists’ ratings.

Macciocchi, Ranseen, & Schmitt (1989) attempted to determine whether neuropsychological functioning during inpatient alcoholism treatment predicted abstinence at one year posttreatment. In this study, neuropsychological functioning was not found to be a significant factor in patients remaining abstinent. That is, many patients who had clear deficits in attention,

concentration, problem-solving, and memory functions nevertheless remained abstinent at one year follow- up. The investigators suggest that in many alcohol- dependent patients, treatment outcome is most likely determined by a variety of psychological and environmental factors generally unrelated to neuropsychological functioning, including the patient’s motivation and denial, as well as the involvement of the patient’s family in treatment.

Comment

According to Goldstein (1987), the attempt to separate motivational from cognitive determinants of task performance is a pseudoissue because, in effect, the brain does not make that separation. The majority of the studies reviewed in this section would seem to support that view. The worst treatment outcome, increased likelihood of relapse, lower educational and employment status, and poorer quality of life in general are associated with lower intelligence and lower levels of cognitive efficiency, particularly in the functions of abstraction, problem-solving, perceptuomotor integration, complex memory, behavioral self-monitoring and self-regulation, language skills, and verbal reasoning - functions that have traditionally been associated in neuropsychology with impaired frontal lobe and/or left hemisphere functioning. In the present model, rather than indicating “lesions” in different brain re- gions, this type of poor-outcome neuropsychological performance pattern probably reflects premorbid, constitutional features of cognitive style that predispose to a lifestyle of dysfunctional abuse of substances.

Thus, individuals with deficient ability to perceive problems and conceive of solutions to them, who lack the capacity to verbally self-monitor, reflect upon, and self-regulate their impulses and behaviors, who have difficulty maintaining a goal-oriented mind-set due to impaired ability to anticipate future consequences, who are likely to perceive important events in their lives as beyond their influence (locus of control), and who, as a result, have a fragmented self-identity with impaired ego-autonomy can be characterized as having an impulsive, nonreflective cognitive style. These individuals may be especially likely to employ psycho- active substances to help modulate their thought processes and feeling states.

In particular, skills involving planning and language appear to play a key role in the cognitive profile of good-outcome substance abusers, perhaps related to their ability to use self-articulatory inner speech as a tool of reflective self-evaluation and self- control (Joseph, 1982; Miller, 1990b, in press a; Vygotsky, 1962). Hypothesized “frontal lobe” or “left hemisphere” neuropsychological impairment may therefore be conceptualized in a functional, develop- mental sense, rather than in the usual meaning of the


neuropsychological clinic; that is, reflecting acquired cerebral damage, or “lesions.”

Indeed, what such neuropsychological tests may be measuring is a kind of generalized “cognitive compen- tency” factor that seems to be predictive of outcome for a wide variety of syndromes and circumstances. For example, a recent study by Harder et al. (1990) comparatively evaluated the prognostic potential of 10 demographic and clinical factors previously associated with psychiatric outcome in a mixed group of psychiatric patients at a community mental health facility. Intellectual level, social class, and the capacity for close interpersonal relationships were the only predictors to show significant correlations with outcome measures of symptom severity and overall adjustment at follow-up, beating out such measures as sex, age, diagnostic severity, race, and stressful life events. It is intriguing that in the studies reviewed above, cognitive competence, as inferred from high neuropsychological performance, tends to be associated with successful self-recovery, while intense group affiliation seems to provide the external support necessary to maintain abstinence for those whose internal coping resources are less well developed. Perhaps we’re already seeing two clusters of substance abuse populations that may require markedly different forms of intervention.

PERSONALITY PREDICTORS OF TREATMENT OUTCOME

There has been a sizable body of research indicating that alcoholics and drug abusers who come to treatment have high rates of emotional disturbances and disorders of impulse control (Grande, Wolf, Schubert, Patterson, & Brocco, 1984; Hesselbrock, Meyer, & Keener, 1985; Powell, Penick, Othmer, Bingham, 8z Rice, 1982; Schuckit, 1985, 1986; Weisman, Meyers, & Harding, 1980). Major depression is the most common diagnosis in female alcoholics and antisocial personality is the most common diagnosis in males (Hesselbrock et al., 1985; Schuckit, 1972; Schuckit & Morrissey, 1976; Schuckit, Pitts, Reich, King, & Winokur, 1969; Winokur, Rimmer, & Reich, 1971). Antisocial personality and/or other comcommitant substance abuse are associated with earlier onset and more severe course of alcoholism, and with increased social problems prior to treatment, while depression is associated with more psychological problems and emotional disturbance during the pretreatment period. With the exception of other substance abuse, no additional diagnoses are clearly linked with increased severity of alcoholism and impaired control of drinking, suggesting that psychopathology per se is not a generalized contributor to alcoholism severity (Edwards, 1986; Edwards, Arif, & Hodgeson, 1981; Hodgeson, Stockwell, Rankin, & Edwards, 1978).

McLellan (1986) has described a research program

that examined several factors contributing to favorable alcohol abuse treatment prognosis across programs of different types. Patients with low degrees of psychiatric severity had the best treatment prognosis generally, and tended to improve significantly in any of the treatment programs to which they were assigned. Patients with high psychiatric severity, on the other hand, showed little or no improvement no matter how much or what type of treatment they received. Further, while psychiatric severity predicted treatment outcome, severity of drug and alcohol abuse, per se, did not. In fact, pretreatment psychiatric severity was a better predictor of posttreatment drinking than was pretreatment drinking.

From a practical standpoint, McLellan (1986) rec- ommends that the majority of these low-psychiatric severity patients be treated in outpatient settings, except when significant family and/or employment problems may warrant a period of inpatient stay. High-psychiatric severity patients, on the other hand, appear to be prime candidates for recidivism and rehospitalization, no matter what kind of treatment they get. Alcohol- and drug-abusing patients with more severe psychiatric disturbance thus may require more focused and independent interventions to address their psychopathology directly through appropriate medication and psychotherapy. However, if treatment outlook is really as dis- mal with this category of patient as the author suggests, it might be more appropriate to seek dispositional al- ternatives through the criminal justice system, rather than the health care system, in cases where substance use is chronically linked to antisocial behavior.

Psychiatric diagnosis was also found to have an effect on posttreatment status in a population of opiate addicts followed for 2.5 years by Rounsaville & Kle- ber (1986). Their study found that depressed addicts were more likely to have disabling medical problems, and had generally poorer psychological functioning during the follow-up period. Antisocial addicts had poorer psychological functioning over the follow-up period, and greater legal and employment problems during that time. Alcoholic addicts had poorer psychological functioning over the follow-up period, were more likely to remain in treatment and abstain from illicit opiates, and were more likely to have disabling medical problems. Addicts with no psychiatric diagnosis at treatment onset had better psychosocial functioning over the 2.5 years and better general functioning at the time of the follow-up interview.

In a subsequent study, Rounsaville, Dolinsky, Babor, & Meyer (1987) carried out a one-year follow- up study on a group of alcoholics who had received extensive psychiatric assessment. They found that, for men, the group with no other psychiatric diagnoses besides alcoholism had the best general outcome. Both major depression and antisocial personality were associated with poorer outcomes, but these outcomes were

282 L. Miller

not distinctly different from those obtained by the group that had any other psychiatric diagnosis-except for abusers of alcohol plus other drugs, whose outcome was worse than that of alcoholics with any other psychiatric disorder. For women, the best alcohol- related treatment outcome was found in the group with major depression. The women with no other psychiatric disorder had generally poorer alcohol-related outcomes that were similar to those observed in patients with antisocial personality and drug abuse.

To explain these results, the investigators note that, among depressed women, the depression was likely to be the primary diagnosis, with onset of alcoholism occurring only subsequent to the onset of depression. They therefore hypothesize that the development of alcoholism may have been an attempt at self-medication for depression, a disorder that is both more common than alcoholism in women (Cloninger et al., 1978; Myers et al., 1984; Robins et al., 1984) and usually associated with a better prognosis than alcoholism.

A group of alcoholics who had been remanded to compulsory treatment by the Swedish Temperance Board were compared with a matched group of non- compulsory-treatment alcoholics by Berglund (1988) in a follow-up study spanning decades. The compulsory treatment group was found to have had more frequent initial ratings of antisociality, criminality, poor social functioning, and impaired work performance that were not related to other psychiatric disturbances such as neuroses or depression, or to environmental stressors. Ratings of slight cerebral dysfunction were strongly associated with continuous drinking in the control group, but not in the compulsory treatment group, corroborating previously found associations (Berglund & Leijonquist, 1978) between cerebral dysfunction and continuous drinking. Slight cerebral dysfunction that was unrelated to continuous drinking, on the other hand, was more frequent in the compulsory treatment group than in the controls. We may speculate that this latter type of “cerebral dysfunction” may have been of the premorbid, constitutional neuropsychological type, discussed above, that is associated with the impulsive cognitive style and antisocial clinical picture (Miller, 1987, 1988, 1990b, 1991, in press).

The compulsory treatment group had a consider- ably higher frequency of deaths related to behavioral aspects of acute and chronic alcohol intoxication, including suicide, alcohol overdose, accidents, violence, and cardiac death. On the other hand, there were no differences concerning the frequencies of liver cirrho- sis or alcohol-related neoplasm, medical complications more directly related to level of consumption, per se. Differences between the groups therefore could probably be explained by differences in drinking patterns, with more episodic drinking and social complications in the compulsory treatment group, and more contin-

uous drinking in the control group, while the total amount of drinking was probably equivalent for the two groups. This is similar to Cloninger’s (1987) dis- tinction between the impulsive/antisocial binge drinker and anxious/depressed consistent daily imbiber, separate patterns of alcohol use that tend to have diver- gent courses and different clinical characteristics.

The relationship between DSM-ZZZ personality disorders and alcoholism treatment outcome was evaluated by Poldrugo & Forti (1988) in a group of alcoholics admitted to the Psychiatric Clinic at the University of Trieste, Italy. The overall frequency of personality disorders among this group of alcoholics was found to be lower than that commonly reported among alcoholics in the U.S. In this Italian sample, alcohol abuse was specifically related to antisocial personality: antisocial subjects had a significantly higher prevalence of alcoholism, while histrionic and compulsive personality disorder subtypes correlated negatively with alcoholism. With regard to treatment outcome, group therapy for alcoholism was not beneficial for antisocial alcoholics, while those with dependent personality disorders did benefit from this treatment. Other types of personality disordered alcoholics showed equivocal treatment effects roughly comparable to those typically reported for alcoholics as a whole.

Marlatt & Gordon (1980) have employed self- efficacy theory (Bandura, 1977, 1982) to develop a cognitive-behavioral model of the relapse process. Ac- cording to this model, drug and alcohol abusers with high self-efficacy about their ability to avoid relapse are more likely to utilize adaptive coping responses and less likely to relapse than subjects with low self- efficacy. Moreover, self-efficacy expectations about relapse are assumed to change systematically as individuals acquire coping skills and accumulate increasing numbers of mastery experiences, such as being able to successfully avoid relapse when confronted with high-risk situations.

Employing this model, Burling, Reilly, Moltzen, & Ziff (1989) examined monthly intreatment ratings of self-efficacy to avoid drug and alcohol abuse in a group of substance abuse inpatients at a residential treatment facility. Posttreatment interviews were con- ducted with a portion of the sample approximately 6 months after discharge to assess the relationship between self-efficacy and relapse. As expected, self- efficacy increased during treatment and was higher among abstainers than among relapsers at follow-up. Contrary to expectation, however, patients who exhibited greater change in self-efficacy while in treatment had higher abstinence rates at follow-up; in fact, abstainers showed a two-fold increase in self-efficacy, compared to relapsers. Thus, the magnitude of intreatment change in self-efficacy may be an important predictor of outcome, and may have important implications for determining which patients will profit most


from treatment, and will have the most favorable prognoses at follow-up.

Another unexpected, but intriguing, finding was that patients with low self-efficacy at the beginning of treatment were better able than high self-efficacy subjects to predict the circumstances of their eventual relapse. The clinical implications are that knowledge of which patients are better at identifying their eventual relapse situations could help clinicians develop individ- ualized treatment plans for each patient.

Kosten, Kosten, & Rounsaville (1989) examined rates of depression, alcoholism, and other specific problems in a group of treated opiate addicts who were followed up after 2.5 years. Of these patients, 80% were found to have a personality disorder diagnosis. Subjects with a diagnosis of borderline personality disorder showed the most serious psychiatric risk for depression and alcoholism at follow-up, while antisocial personality-disordered addicts had more legal problems. The presence of other personality disorders was not associated with greater risk of problem severity.

While not focusing on recovery versus relapse, per se, Craig, Olson, 8z Shalton (1990) compared opiate and cocaine abusers who had received hospital-based, “multimodel” treatment for drug abuse with another group of drug abusers in a methadone maintenance program. Results showed that the short-term, hospital- based, multimodal program produced significant changes in psychological functioning of the opiate and cocaine abusers, whereas an equivalent length of outpatient treatment on methadone maintenance produced no changes in psychological functioning. A composite picture of the typical product of the multimodal program would be

a person who now has increased motivation and a renewed sense of determination and confidence to achieve goals, has an increased level of aspiration and a willingness to persist in tasks and goals, has an improved capacity to endure set- backs, has shown a greater willingness to elicit sympathy and support from significant others, and has reduced the need for autonomy, which may have shut off support systems in the past. They show less tendencies to demean themselves, have a more positive attitude towards life, and feel less personal alienation. (Craig, Olson, & Shalton, 1990, p. 15)

The investigators point out, however, that these psychological gains made in the multimodal treatment group were aggregate gains, averaged over the entire group. This means that some patients improved substantially, while others only showed moderate improvement, and a few others probably showed little or no change in functioning. They urge that future research should identify those patients who made maxi- mal improvement in the multimodal program and those patients who showed no changes, and should then compare these groups to other outcome criteria, such as abstinence. From our present perspective, it might

be supposed-judging from the statement above-that the “improvers” in the multimodal program were characterized by the type of qualities we have been re- ferring to in connection with ego autonomy and a reflective cognitive style. These characteristics, present from the start, may have been a selection factor in the appropriateness of the multimodal program for these individuals.

While most research in recovery and relapse has dealt with the usual kinds of clinical substance abuse treatment populations, two recent studies examined the outcomes of those who usually find themselves on the other side of the treatment process: psychologists and physicians. Thoreson, Budd, & Krauskopf (1986) investigated the demographic, alcohol and drug use characteristics, work behavior, and recovery experiences of a group of alcoholic psychologists in an abstinence-based recovery organization, Psychologists Helping Psychologists. Respondents were similar in most respects to other psychologists in the American Psychological Association and to other health professionals with drug and alcohol problems.

The results indicated that, despite major alcohol- dependence symptoms, a pattern of multiple drug use, and demonstrable work impairment during their active drinking, the psychologists showed an overall excellent level and quality of recovery from alcoholism. Fur- ther, there was a tendency for respondents with longer sobriety to use a variety of relapse-prevention strategies and to use them more frequently, as well as to become more involved in the AA program.

Galanter, Talbott, Gallegos, and Rubenstone (1990) studied a group of physicians in the Impaired Physicians Program, who were successfully treated in a program, “Caduceus,” that combined professionally directed psychotherapeutic treatment and peer-led self-help. An average of 33 months after admission, they all reported being abstinent and rated AA as more important to their recovery than professionally directed modalities. Three main psychological factors were found to have influenced commitment to the AA philosophy and its effects on recovery:

1) Shared beliefs: The intensity of subjects’ commitment to AA was highly correlated with their perception of why they were successful in maintaining a stable recovery. AA was regarded by the patient-doctors as more influential than the treating doctors who were responsible for their care. 2) Group cohensiveness: The close camaraderie promoted by AA was perceived to stand in contrast to the clinical and more detached ambience of most psychiatric facilities. Subjects felt closer to their AA compatriots than they felt toward the outsiders they knew best; the magnitude of this co- hesiveness was comparable to that observed among members of a zealous, communal religious sect. 3) Mutual identification: Acquiring a social role compat- ible with recovery accorded the alcoholic physicians a

284 L. Miller

more stable abstinence, and this emerged as he or she assumed the role of a professional caregiver in the addiction field. In the Caduceus program, the physician is in close continuing contact with other physicians who have achieved a stable recovery. We may thus speculate that the special enthusiasm shown for these programs by the member-physicians and psychologists was in large part associated with the homogeneity and resultant fellow-feeling of the groups; much wider variation in occupational and social status exists in the typical AA group that serves the community as a whole.

Comment

Personality and psychopathology characteristics associated with poor alcohol and drug abuse treatment outcome include antisocial or borderline personality, depression, and concommitant substance abuse. In addition, any kind of psychiatric disturbance, if severe enough, bodes ill for substance abuse recovery. Con- versely, subjects with higher levels of self-efficacy or ego autonomy do well in treatment and maintain abstinence goals in the period following treatment. In fact, given the kernel of self-efficacy to start with, substantial increases in this trait may be observed as the result of proper therapy.

Individuals from higher educational and social classes - psychologists and physicians - seem to do well in treatment. Such individuals obviously have much to lose from a continued life-pattern of alcoholic dissipation, which would provide powerful motivation for maintaining recovery gains. But for such individuals to have reached their professional posi- tions in the first place implies a requisite degree of intelligence and ability to sustain goal-orientation, a task largely beyond those with a primarily impulsive, nonreflective cognitive style. Even for these professionals, however, the external support provided by AA-type group affiliation is regarded as one of the key factors in maintaining their recovery. On the other hand, “self-reliance” in a group, if not an individual sense, appears to be valued more than traditional methods of treatment, especially when the groups are composed of members with similar backgrounds.

Yet some apparently successful recoverers eschew even these kinds of group support modalities and pre- fer to “go it alone.” It would be of great interest and importance to examine how some individuals manage to recover using only, or at least mainly, their own inner resources.

“SPONTANEOUS” OR SELF-RECOVERY FROM SUBSTANCE ABUSE

A small, but growing literature has begun to address this issue of self-recovery. The combined results may

have profound implications for our traditional notions of substance abuse “treatment.”

The life histories of a group of men and women who resolved their chronic drinking problems without professional or formal treatment were analyzed by Tuchfield (1981) to determine whether and by what means spontaneous remission of alcoholism occurs. One important finding was the strong resistance shown by the self-recoverers to labeling themselves as “alcoholics,” and the general antipathy displayed toward institutional forms of treatment, whether hospital rehab programs or AA-type support groups. Instead, although acknowledging the roles of such informal influences as social support and religion, these individuals were quite proud of their ability to resolve their alcohol problems on their own.

For these subjects, a number of specific kinds of experiences seemed to be responsible for precipitating their decision and firming their resolve to quit drinking. Financial problems, legal difficulties, or “education” programs about alcoholism actually seemed to play a minor role, while health factors (including de- bilitating hangovers) and concern for loved ones did appear to be important. In some cases, quitting drinking coincided with quitting smoking, as part of a general, overall lifestyle change, and a number of subjects who had previously given up cigarettes were apparently sufficiently bolstered by this success to make the subsequent decision to abjure the bottle.

Where loved ones were a factor, most self-quitters had strong backing from family members, but in at least one case, abstinence was initiated and maintained despite lack of support from the spouse. Unexpected critical events, like the death of a loved one, could precipitate self-quitting, as could other extraordinary events, whose connection to drinking may have seemed objectively irrational, but which apparently made sense to the quitter. Where religion had an effect, it was typically in the form of an incremental process of commitment, rather than a dramatic conversion experience, although a few cases of the latter did occur.

In most cases, a person’s initial commitment to change was not by itself sufficient to sustain momen- tum toward continued sobriety and problem resolu- tion. A variety of social conditions proved to be important maintenance factors. These included the availability of nonalcohol-related leisure activities, reinforcement from family and friends, and the existence of relatively stable social and economic support systems. There appeared to be a selection process whereby beginning recoverers actively sought out nonalcohol situations and circumstances that would serve as informal social controls.

Some subjects reported that acceptance of their al- tered situations was accompanied by positive changes in self-concept. This self-acceptance was often related to a process of “identity transformation” whereby the person now felt himself or herself to be in a position


to assist someone else, to assume a “helper” role, as opposed to a previously passive, dependent, patient- like “helpless” role. Some subjects adopted “justifying rhetorics” to explain former drinking patterns, and a number had become well-read “experts” on alcohol issues, although such self-education tended to be eclec- tic, drawing from different general philosophies.

Tuchfield (1981) points out that most treatment programs for alcoholism and substance abuse include an explicit or implicit requirement for accepting the “alcoholic” (or equivalent) label. The process of self- recovery, on the other hand, focuses on the internally generated factors and social conditions that facilitate positive changes in alcohol-related behaviors and self- definitions, without necessarily requiring the acceptance of a stigmatizing label. And, where most treatment programs are typically concerned with appropriate institutional controls, the supports observed in the present subjects were grounded in informal social control.

The process of “spontaneous,” or self-remission of alcoholism was also studied by Ludwig (1985). In his sample, the primary reasons offered for the initiation of recovery pertained less to specific life events or external circumstances, such as legal employment or family problems, than to the subject’s state of mind, and his perception of his situation. Both elevating “peak experiences” and demeaning “hitting-bottom” events had a motivating influence toward sobriety, probably because both types of events dramatically capture the alcoholic’s attention and jolt him or her emotionally-albeit from different directions.

However, not all alcoholics required this kind of profoundly uplifting or degrading experience. A small percentage claimed that they began to see clearly where they were headed if they continued their drunken ways. Although just as severely alcohol-impaired as those subjects reporting “hitting bottom,” this other subgroup did not necessarily regard their lifestyle change decision as stemming from a personal low point in their lives. Instead, their decision to quit drinking, although in many cases spurred by discrete, external events, seemed mostly of a more quietly de- liberative, existential nature. They concluded that the future negative consequences of continued alcohol consumption far outweighed any potential pleasures gained in the short term.

Other subjects appeared to develop a physical aversion, a self-described “allergy” to alcohol. Although they wished they could still drink, the physically unpleasant effects deterred them-almost as if they had a built-in “Antabuse reaction.” Still other subjects, with no such noxious physical reactions, reported that, shortly after having made their final decision to quit, their craving for alcohol-what had once been an “irresistable urge” -dissipated entirely, and that maintaining abstinence was now no big deal. Most subjects, unfortunately, were not so lucky. They pe- riodically had to struggle with the urge to drink,

toughing out the periods of greatest temptation, particularly over the first year or two of their recovery. Thereafter, however, their craving appeared to dimin- ish progressively.

Whereas Tuchfield (1981) focused on the relevance of nonalcohol-related activities, reinforcement from family and friends, and the existence of relatively stable social and economic support systems in the maintenance of recovery, Ludwig’s (1985) conceptualization appeals to a far more ineffable ingredient, which he believes to be essential for recovery: the exercise of individual willpower. Prior to the decision to alter their drinking behavior, virtually all subjects reported pleasant connotations to the thought of consuming alcohol - the taste, the “buzz” or “glow,” and so on. Such vivid mental imagery not surprisingly evoked a strong urge to drink. In contrast, after the decision to abstain, two different types of thought patterns emerged. For about half the subjects, the idea of consuming an alcoholic beverage immediately and automatically evoked powerful negative thoughts and feelings-shame, disgust, nausea, etc. For the rest, positive associations with thoughts of drinking still occurred, but as the train of thought continued, the mental associations to drinking became progressively more unpleasant until they eliminated any further desire for alcohol.

Ludwig (1985) comments:

It is fascinating that virtually all of the respondents, regardless of their diverse routes toward recovery, arrived at a common cognitive destination: mental associations to alcohol with very unpleasant, sickening, humiliating or distaste- ful experiences of a personal nature. Interestingly enough, it was not the image of others in distress but the image of themselves suffering the misery that kept them from drinking. It is tempting to conclude from these findings that specific types of cognitions may be crucial in all instances of recovery from alcoholism, even those instances induced by more orthodox means. (Ludwig, 1985, p. 57)

Nordstrom & Berglund (1986) followed up a cohort of recovered male alcoholics two decades after their first admission to inpatient treatment. In this group “spontaneous” remission was the rule. Only one out of five subjects stated that treatment had been the main cause of improvement. Negative social consequences of alcohol abuse, changes in social circumstances, or social pressure to stop drinking were reported as the main causes of improvement by over two-thirds of the subjects. “Hitting bottom” or facing some overarch- ing responsibility had been of importance in about two-thirds of subjects. A minority attributed their improvement mainly to treatment, and an even smaller subset credited AA. However, almost two-thirds stated that at least some kind of treatment had been important at least at some point in recovery, although it was hardly the main factor in maintaining recovery.

The investigators point out that while treatment may possibly add to the beneficial effect of other

286 L. Miller

change-promoting factors, a more likely interpretation is that seeking treatment may be just another expression of an urge to change the drinking behavior, leading to a temporal, but not necessarily causal correlation between treatment and improvement. Also noteworthy was the correlation between personality disturbance (as assessed at initial rating), characterized by lack of internal control of behavior, and the attribution of improvement to social pressure to stop drinking.

While most studies of outcome, “spontaneous” or otherwise, have concentrated on how former heavy alcohol and drug users change their habits and lifestyles, less attention has been paid to why some individuals- some of whom may seemingly be at high risk for the development of substance abuse problems-manage to avoid this fate in the first place. Why, in other words, do some people simply not drink?

Drinking practices and attitudes toward alcohol among the members of a church in Southhampton, England, were investigated by Hughes, Stewart, & Barraclough (1985). Teetotalers tended to be older than drinkers, and included a higher proportion of women. Most of this group came from teetotaler backgrounds, felt emotionally close to their parents and accepting of their ways, had married other teetotalers, and were bringing their own children up to be teetotalers.

Both teetotalism and dysfunctional alcoholism were more common among blood relatives of teetotalers than among relatives of social drinkers, suggesting that some children brought up in homes where drink is strictly prohibited may rebel into alcoholic overin- dulgence, or, alternatively, that the presence of an alcoholic in a family may lead some other relatives to eschew drink completely. Religion was also an important influence for most of the teetotalers. Subjects who had been converted to Christianity in adult life had often given up alcohol at the same time, perhaps because they desired some outward expression of their faith. It was notable that the Bible’s statements on alcohol were differently interpreted according to subjects’ own views on drink.

A study by Werner (1986) focused on child characteristics and on the qualities of the caregiving environment in a multiracial at-risk cohort of Hawaiian children of alcoholics.

A number of behavioral characteristics were found to differentiate the offspring of alcoholics who did not develop any serious coping problems in childhood and adolescence from those who did. These included 1) temperamental characteristics that elicited positive attention from primary caretakers, including substi- tute parents; 2) at least average intelligence and adequate communication skills in reading and writing; 3) “achievement orientation;” 4) a responsible, caring attitude; 5) a positive self-concept; 6) a more internal locus of control; and 7) belief in self-help.

Also, several qualities of the caregiving environment distinguished the “resilient” offspring of alcoholics from those who developed serious coping problems by age 18. These included 1) plenty of attention received from the primary caregiver during infancy, and the absence of any prolonged separation from the caregiver; 2) no attention-diverting additional births into the family during the first two years of life; and 3) the absence of conflict between the parents during those first two years.

Werner (1986) takes these findings as evidence for a bidirectional, transactional model of child-caregiver effects. That is, to the extent that these children were able to elicit mainly positive responses from their caregiving environment, they were found to be stress-resis- tant, despite parental alcoholism and chronic poverty. But if they elicited negative responses from their caregivers, especially if the mother or both parents were problem drinkers and there were no adequate substi- tute caregivers, they were vulnerable. Thus, it appeared not to be solely the risk of parental alcoholism, but the balance between that risk factor, the accumu- lation of stressful life events, and protective factors within the child and his caregiving environment that accounted for the range of adaptive and maladaptive outcomes observed among the offspring of alcoholics in this study.

Cognitive dimensions associated with self-regulation of alcohol consumption were studied in a large sample of students at nine universities by Greenfield, Guydish, & Temple (1989). The reasons these students gave for limiting their drinking included internalized references for self-control, regard for external author- ities like religion or parents, attempts at self-reform, positive performance aspirations, and specific antici- pated role demands, such as having to drive.

Significantly, reasons for limiting drinking that had to do with internalized controls and standards and/or factors related to early upbringing were associated with successful drinking limitation and absence of excessive binge drinking. Conversely, reasons related to “self-reform” based on external pressures and motiva- tions did not seem very effective in limiting excessive drinking. The investigators caution that cognitions urging “self-restraint” in the face of feedback that drinking has caused problems appear ineffective at best, and might even be harmful. Hypothetically, the effect of this kind of cognitive set might be mitigated if internalized self-control beliefs coexisted or were strengthened in counseling.

Comment

Factors that seem to characterize “spontaneous,” or self-recoverers, as well as high-risk subjects who avoid dysfunctional substance abuse, include profound or dramatic experiences, although more quiet, “existen-


tial” decisions occur also; resistance to the “alcoholic” or “addict” label, and to institutional or support group forms of treatment such as hospitals, doctors, or AA; adequate intellectual ability and good verbal skills; a future orientation that allows subjects to struggle through initial doubts and temptations, see past imme- diate positive associations to drinking and evoke mental imagery of more long-term negative consequences; internal locus of control, self-efficacy, and a change (usually in a positive direction) in identity and self- concept. These are precisely the neurocognitive and personological qualities associated more generally with individuals high in ego autonomy and characterized by a reflective cognitive style (Hartmann, 1939; Miller, 1989a, 1990b, 1991, in press).

As a clinical aside, the development of a physiolog- ical aversion to alcohol in some individuals deserves further study, since it may not be so rare a phenomenon as first thought. The present author has seen two cases which come close to Ludwig’s (1985) description of acquired aversion to alcohol. The first occurred in a 45year-old woman, with a 20-year history of problem drinking and a reputation for being a gal who could “hold her liquor” in particularly prodigious quantities, who rather abruptly developed explosive headaches with nausea and vomiting following even small amounts of alcohol. There was a history of mild, common migraines since adolescence, which came on approximately once a month, and still occurred independent of drinking; the severe “killer migraines” were now restricted to drinking. In this case, the diagnosis of migraine was confirmed by history and by neurologic workup. Interestingly, an older sis- ter had been “turned off” to alcohol since high school because of similar, but earlier-onset “killer” headaches related to drinking. The second case involved a 57- year-old man, an episodic, self-described “weekend drunk,” who also developed headaches and nausea, accompanied by dizziness, with small amounts of alcohol-“like an instant hangover.” In this case, the intensity of the aversion built up gradually over months, there was no family history of migraine, and neurologic findings were normal.

Stall & Biernacki (1986) comprehensively reviewed the literature on spontaneous remission from four substances-alcohol, opiates, food (compulsive over- eating/obesity), and tobacco-selected for their widely variant meanings within the mainstream North Amer- ican culture. They identified the common processes important to spontaneous remission from these four substances, and they use this data to derive a model of spontaneous remission behavior. The main factors commonly found to be related to spontaneous remission from these four substances are: 1) health problems, 2) social sanctions, 3) the influence of significant others, 4) financial problems, 5) major accidents, 6) management of cravings, 7) positive reinforcement for

quitting, 8) internal, psychological change or increased motivation, and 9) change in lifestyle.

Although the meaning of some of these factors is relatively self-explanatory, the authors elaborate on several others. “Significant accidents” typically involves a mysticoreligious, seemingly miraculous escape from serious injury or major trouble with the law, which forces the abrupt realization of the true, potentially dire, consequences of the substance abuse. “Management of craving” refers to attempts by the remitter to lessen cravings through such substitutes as jogging, meditation, or absorption in work. “Change in lifestyle” involves avoiding situations and circumstances likely to provide temptation, and “positive reinforcement for quitting” occurs when the remitter experiences some of the happier consequences of end- ing his or her problematic substance use, such as mornings without hangovers, or compliments on ap- pearance after weight loss.

The authors point out that within the prevailing “disease model” of addiction, substance abusers are necessarily seen as “sick,” and therefore to be sub- jected to extensive -and frequently expensive - “treatment.” The subject of spontaneous remission has received scant attention within the substance abuse treatment community, no doubt partly because the treatment industry finds little profit in individuals who get better on their own. Spontaneous remitters don’t fill the hospital beds and don’t require cadres of treatment personnel.

Stall & Biernacki (1986) maintain that the prevailing substance abuse treatment policy in the United States is based on the assumption that such problems are intractable and permanent, thus requiring inten- sive and prolonged professional clinical intervention. Instead, the data reviewed by these authors-as well as that discussed above in the present review-suggests that the process of internal and public renegotiation of a stigmatized identity underlies the spontaneous re-. mission phenomenon, and health policy concerning substance use should accordingly be based on the assumption that problematic addiction careers can be a temporary and self-alterable phase in the life course. Consistent with this, care should be taken during the intervention process that the self-definition of “alcoholic” or “addict” not become an indelible part of the user’s private and social identity-just the opposite of the majority of most AA-model treatment approaches. Of course, as the data in the present review suggest, this approach may work for certain types of substance abusers and not for others.

IMPLICATIONS FOR TREATMENT

Recently, there have been a number of recommendations for revamping both the basic philosophy and practical application of substance abuse treatment in

288 L. Miller

the United States-specifically, for substituting more cost-effective and potentially more clinically effica- cious day treatment for the usual hospital inpatient substance abuse regimen. As the present review suggests, the success of such innovative programs may well depend on what type of patient they treat.

According to Schneider & Googins (1989), the enormous growth of inpatient alcoholism treatment programs in recent years (U.S. Department of Health & Human Services, 1987) has been fueled by the acceptance of the disease model, the willingness of insurers to reimburse for inpatient treatment, and the increasing number of referrals originating from employee assistance programs (EAPs) and other treatment providers. Since health care insurers have generally offered little or no coverage for day treatment or for any alcoholism treatment other than inpatient detoxification and rehabilitation, there has been no business incentive to develop alternative treatments.

In this analysis, the rapid increase in hospital programs for alcoholics and drug abusers during the same period of decreasing profits in the health care industry as a whole is no coincidence. Substance abuse treatment programs help to fill beds and justify the addition of new beds at a time when length of stay in hospitals has been sharply curtailed through new tech- nologies and cost containment strategies. Second, substance abuse beds are relatively cheap since they require minimal medical coverage and little or no expensive testing or equipment. This translates into a high profit- margin incentive for hospitals to develop and market these kinds of programs.

The sharp resistance that day treatment has met from the health insurance industry is surprising, con- sidering the potential of tremendous cost savings, compared to inpatient treatment. It would seem that the newly-developed alcoholism treatment facilities represent a substantial investment by hospitals, which could be threatened by the increasing acceptance of day treatment. Therefore, investment in such facilities eliminates any incentive for them to pressure insurance companies to cover alternative modalities. In fact, quite strident efforts in the opposite direction are more often the case. From this perspective, day treatment becomes a sensitive political issue rather than a researchable question of treatment effectiveness.

Demonstrating the treatment effectiveness of substance abuse day programs must, however, be a necessary first step if any objective credibility at all is to be maintained. Given the data discussed in the present review, it will probably turn out that both innovative day programs and traditional inpatient facilities will each have their areas of respective clinical strength, depending on what different types of substance abuse populations they serve. And in this regard, the neuropsychological, personality, and cognitive style factors discussed above may prove to be the primary differ- entiating variables.

For example, consider the Cognitive-Behavioral Relapse Prevention (CRP) approach, originally developed by Marlatt & Gordon (1980, 1985) and adapted and elaborated by George (1989). CRP derives from social cognitive theory (Bandura, 1969, 1977, 1986) which, in turn, combines ideas from cognitive psychology, social psychology, and behavior modification. With regard to substance abuse, the key theoretical as- sumptions of CRP include the following:

Addictions are jointly caused by past learning, sit- uational antecedents, reinforcement contingencies (rewards and punishments), cognitive expectations (beliefs), and biological influences. The behavior exists on a continuum between nonproblematic expression (e.g., social drinking) and addictive or otherwise dysfunctional expression (e.g., alcoholism). Thus, the same principles can be used to explain acquisition and maintenance of both nonaddictive and addictive behavior. The addiction is a maladaptive coping response to life stressors and problems. Presumably, more adaptive coping responses are not utilized by the person, and the addictive behavior has evolved as a habitual replacement response for this deficiency.

An underlying and pervasive feature of all CRP treatment is self-efficacy enhancement. To promote the individual’s self-efficacy, employment of the various training techniques are accompanied by instructions to imagine that the rehearsed experience is accompanied by mounting feelings of competence and confidence. As a result, the person experiences heightened expectations of successful coping in future, real-life situations, thereby reducing the probability of relapse.

Another alcohol relapse prevention treatment program that is based explicitly on self-efficacy theory is that of Annis & Davis (1989). Their model proposes that when a client enters a high-risk situation for drinking, a process of cognitive appraisal of past experiences is set in motion that culminates in a judgment, or “efficacy expectation,” on the client’s part of his or her ability to cope with the situation. This judgment of personal efficacy determines whether or not drinking takes place.

The program makes the important innovation of recognizing that it may be maximally effective with certain types of clients and not with others. Accord- ingly, a crucial part of the evaluation process consists of careful screening for client suitability. The model of behavior change that underlies the program assumes the existence of adequate motivation, that clients perceive some benefit in working with the therapist toward greater control of their drinking behavior. It is therefore unlikely that such an approach would be effective with, for example, a homeless alcoholic with few incentives to stop drinking, or an impulsive, antisocial, alcoholic offender who is remanded to “treatment” as a convenient way of avoiding the criminal justice system. Thus, to the extent that sufficient internalized incentives exist for changing drinking be-


havior, this kind of relapse prevention program can fit from abstinence or control. When confronted with serve as a means of narrowing the gap between con- urges or temptations to drink, the client should be able templation and action, of demonstrating to the client to distract himself or herself by thinking of other that change can be gradual and relatively nonthreat- things, or by imagining a positive outcome- just the ening, and thus of motivating the client to attempt to kinds of tactics employed spontaneously by Tuch- control his or her drinking. field’s (198 1) and Ludwig’s (1985) self-recoverers.

This program also takes into account the belief SYS-

tern of the client. Some clients feel strongly that their drinking problems are a reflection of deep-rooted PSY-

chological conflicts, and may insist on a psychody- namic approach to therapy, in which case relapse prevention procedures would be of little utility. More commonly, clients will come to treatment expecting the therapist or the treatment program to take full control and solve their drinking problems. These individuals must learn that it is necessary for them to take an active role in the design of “homework assignments” in their everyday settings so that they, in effect, become their own therapists or maintenance agents.

Relapse prevention training may be directed toward either an abstinence or a moderation goal, a flexibility that might alienate clients committed to a disease model and/or to the AA philosophy. Indeed, there is evidence that client adherence to the rigid belief of “one drink, one drunk” is associated with increased probability of posttreatment relapse (Heather, Roll- nick, 8z Winston, 1983). However, such AA-type af- filiations do not automatically preclude benefitting from relapse prevention training, as long as partici- pants accept the value of learning to prevent relapse by dealing more effectively with high-risk drinking situations. Finally, research on the relapse prevention model suggests that clients who have clearly defined areas of drinking risk benefit more from brief relapse prevention training than do clients whose drinking is more generalized across situations.

With regard to the effectiveness of relapse prevention training, a study by Annis, Davies, Graham, & Levinson (1987) randomly assigned a group of alcoholics who had recently completed a 3-week inpatient program to receive either relapse prevention training or more traditional counseling on an outpatient basis. Each client was classified as having either a “generalized profile” (similar drinking across all types of high- risk situations) or a “differentiated profile” (greater drinking risk in some type of situations than in others). Results at 6-month follow-up showed no differences for subjects with undifferentiated profiles across the two treatment conditions in the daily amount of alcohol consumed; however, subjects with differentiated profiles showed a substantially lower alcohol intake with relapse prevention training than with traditional counseling.

Another important component of the relapse prevention program is identifying the strengths, resources, supports, and coping skills already available to the client, which then form the groundwork for the development of successful homework assignments. Coping responses that the client may have been using successfully in other areas may be quite effective, with only minor alterations, in addressing problematic drinking situations. Significant others, such as a spouse or employer, may be willing to provide support, encouragement, and even active involvement in helping the client address his or her drinking problem.

In sum, we must acknowledge that, as substance abusers differ, so must our handling of them. Those with sufficient ego autonomy, and with cognitive styles conducive to reflection, future-orientation, frus- tration-tolerance, communication skill, internal locus of control, and goal-maintenance-what the neuro- psychologists associate with intact language and frontal lobe functions-might benefit optimally from flexibly structured, self-directed forms of day treatment-type programs. Conversely, the impulsive, cognitively deficient, internal resource-poor alcoholic or drug abuser would be more suited to a tightly-structured, externally supportive inpatient program. Only by understanding and dealing with the heterogeneity of the substance abuse clientele we serve-indeed, part of the larger natural diversity in virtually all clinical populations - will we be able to design and implement more effective and meaningful interventions.

REFERENCES

Abbot, M.W., & Gregson, R.A.M. (1981). Cognitive dysfunction in the prediction of relapse in alcoholics. Journal of Studies on Alcohol, 42, 230-243.

Of significance to the present discussion, one important client resource identified by Annis & Davis (1989) as being important to the success of relapse prevention is called cognitive coping. This describes the ability to reason things out, to see connections between actions and consequences, and to plan alternative ways of dealing with a situation. The client should be able to appreciate the positive benefits of not drinking and believe that he or she would personally bene-

Annis, H.M., & Davis, C.S. (1989). Relapse prevention. In R.K. Hester 8c W.R. Miier (Bds.), Handbook of aicohobm treatment approaches (pp. 170-182). New York: Pergamon.

Annis, H.M., Davis, C.S., Graham, M., & Levinson, T. (1987). A controlled trial of relapse prevention procedures based on self- efficacy theory. Unpublished manuscript.

Bandura, A. (1%9). Principles of behavior modification. New York: Holt, Rinehart and Winston.

Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.

Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37, 122-147.

Bandura, A. (1986). Social foundations of thought and action: A

290 L. Miller

social cognitive perspective. Englewood Cliffs, NJ: Prentice- Hall.

Berglund, M. (1988). Alcoholics committed to treatment: A prospec- tive long-term study of behavioral characteristics, mortality, and social adjustment. Alcoholism: Clinical and Experimental Re- search, 12, 19-24.

Berglund, M., & Leijonquist, H. (1978). Prediction of cerebral dysfunction in alcoholics: A study of health insurance records. Jour- nal of Studies on Alcohol, 39, 1968-1974.

Burling, T.A., Reilly, P.M., Moltzen, J.O., & Ziff, DC. (1989). Self-efficacy and relapse among inpatient drug and alcohol abusers: A predictor of outcome. Journal of Studies on Alcohol, 50, 354-360.

Chastian, R.L., Lehman, W.E.K., & Joe, G.W. (1986). Estimated intelligence and long-term outcomes of opioid addicts. Ameri- can Journal of Drug and Alcohol Abuse, 12, 331-340.

Cloninger, C.R. (1987). Neurogenetic adaptive mechanisms in alcoholism. Science, 236, 410-416.

Cloninger, C.R., Christiansen, K.O., Reich, T., & Gottesman, 1.1. (1978). Implications of sex differences in prevalences of antisocial personality, aIcoholism, and criminality for familial trans- mission. Archives of General Psychiatry, 35, 941-951.

Craig, R.J., Olson, R., & Shalton, G. (1990). Improvement in psychological functioning among drug abusers: Inpatient treatment compared to outpatient methadone maintenance. Journal of Substance Abuse Treatment, 7, 11-19.

Donovan, D.M., Kivlahan, D.R., & Walker, R.D. (1984). Clinical limitations of neuropsychological testing in predicting treatment outcome among alcoholics.

Edwards, G. (1986). The alcohol dependence syndrome: A concept as stimulus to inquiry. British Journal of Addiction, 81, 171-183.

Edwards, G., Arif, A., & Hodgeson, R. (1981). Nomenclature and classification of drug and alcohol related problems. Bulletin of the World Health Organization, 59, 225-242.

Galanter, M., Talbott, D., Gallegos, K., & Rubenstone, E. (1990). Combined Alcoholics Anonymous and professional care for ad- dicted physicians. American Journal of Psychiatry, 147, 64-68.

George, W.H. (1989). Marlatt and Gordon’s relapse prevention model: A cognitive-behavioral approach to understanding and preventing relapse. Journal of Chemical Dependency Treatment, 2, 125-152.

Goldstein, G. (1987). Recovery, treatment and rehabilitation in chronic alcoholics. In O.A. Parsons, N. Butters, & P. Nathan (Eds.), Neuropsychology of alcoholism: Implications for diagnosis and treatment (pp. 361-377). New York: Guilford.

Grande, T.P., Wolf, A.W., Schubert, D&P., Patterson, M.B., & Brocco, K. (1984). Associations among alcoholism, drug abuse, and antisocial personality: A review of the literature. Psycholog- ical Reports, 55, 455-474.

Greenfield, T.K., Guydish, J., & Temple, M.T. (1989). Reasons students give for limiting drinking: A factor analysis with implications for research and practice. Journal of Studies on Alcohol, 50, 108-115.

Gregson, R.A.M., &Taylor, G.M. (1977). Prediction of relapse in men alcoholics. Journal of Studies on Alcohol, 38, 1749-1760.

Harder, D.W., Strauss, J.S., Greenwald, D.F., Kokes, R.F., Rotzler, B.A., & Gift, T.E. (1990). Predictors of outcome among adult psychiatric first-admissions. Journal of Clinical Psychologv, 46, 119-128.

Hartmann, H. (1939/1958). Ego psychology and theproblem of ad- aptation. New York: International Universities Press.

Heather, N., Rollnick, S., &Winston, M. (1983). A comparison of objective and subjective measures of alcohol dependence as predictors of relapse following treatment. British Journal of Clin- ical Psychology, 22, 11-17.

Hesselbrock, M.N., Meyer, R.E., & Keener, J.J. (1985). Psychopa- thology in hospitalized alcoholics. Archives of General Psy- chiatry, 42, 1050-1055.

Hodgeson, R., Stockwell, T., Rankin, H., & Edwards, G. (1978). Alcohol dependence: The concept, its utility and measurement. British Journal of Addiction, 73, 339-342.

Hughes, J., Stewart, M., & Barraclough, B. (1985). Why teetotallers abstain. British Journal of Psychiatry, 146, 204-208.

Joseph, R. (1982). The neuropsychology of development: Hemi- spheric laterality, limbic language and the origin of thought. Journal of Clinical Psychology, 38, 4-33.

Klein, G.S. (1954). Need and regulation. In M.R. Jones (Ed.), Ne- braska Symposium on Motivation (pp. 224-274). Lincoln: Uni- versity of Nebraska Press.

Kosten, T.A., Kosten, T.R., & Rounsaville, B.J. (1989). Personal- ity disorders in opiate addicts show prognostic specificity. Jour- nal of Substance Abuse Treatment, 6, 163-168.

Kupke, T., & O’Brien, W. (1985). Neuropsychological impairment and behavioral limitations exhibited within an alcohol treatment program. Journal of Clinical and Experimental Psychology, 7, 292-304.

Leber, W.R., Parson, O.A., &Nichols, N. (1985). Neuropsycholog- ical test results are related to ratings of men alcoholics’ therapeutic progress: A replicated study. Journal of Studies on Alcohol, 46, 116-121.

Ludwig, A.M. (1985). Cognitive processes associated with “spontaneous” recovery from alcoholism. Journal of Studies on AI- cohol, 46, 53-58.

Macciocchi, S.N., Ranseen, J.D., & Schmitt, EA. (1989). The relationship between neuropsychological impairment in alcoholics and treatment outcome at one year. Archives of Clinical Neuropsychology, 4, 365-370.

Marlatt, G.A., & Gordon, J.R. (1980). Determinants of relapse: Im- plications for the maintenance of behavior change. In P.O. Da- vidson & SM. Davidson (Eds.), Behavioral medicine: Changing health lifestyles (pp. 410-452). New York: Brunner/Mazel.

Marlatt, G.A., &Gordon, J.R. (Eds.). (1985). Relapseprevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford.

McLellan, A.T. (1986). “Psychiatric severity” as a predictor of outcome from substance abuse treatments. In R.E. Meyer (Ed.), Psychopathology and addictive disorders (pp. 97-139). New York: Guilford.

Miller, L. (1985). Neuropsychological assessment of substance abusers: Review and recommendations. Journal of Substance Abuse Treatment, 2, 5-17.

Miller, L. (1986). “Narrow localizationism” in psychiatric neuropsychology. Psychological Medicine, 16, 729-734.

Miller, L. (1987). Neuropsychology of the aggressive psychopath: An integrative review. Aggressive Behavior, 13, 119-140.

Miller, L. (1988). NeuropsychoIogicaI perspectives on delinquency. Behavioral Sciences and the Law, 6, 409-428.

Miller, L. (1989a). Neurocognitive aspects of remorse: Impulsivity- compulsivity-reflectivity. In E.M. Stern (Ed.), Psychotherapy and the remorsefulpatient (pp. 63-76). New York: Haworth.

Miller, L. (1989b). Neuropsychology, personality and substance abuse: Implications for head injury rehabilitation. Cognitive Re- habilitation, 7, 26-31.

Miller, L. (1990a). Neuropsychodynamics of alcoholism and addiction: Personality, psychopathology and cognitive style. Journal of Substance Abuse Treatment, 1, 31-49.

Miller, L. (1990b). Inner natures: Brain, selA andpersonality. New York: St. Martin’s Press.

Miller, L. (1991). Brain and self: Toward a neuropsychodynamic model of ego autonomy and personality. Journal of the Amer- ican Academy of Psychoanalysis, 19,213-234.

Miller, L. (in press). The primitive personality and the organic personality: A neuropsychodynamic model for evaluation and treatment. Psychoanalytic Psychology.

Myers, J.K., Weissman. M.M., Tischler, G.L., Holzer, C.E., Leaf, P.J., Orvaschel, H., Anthony, J.C.. Boyd, J.H., Burke, J.D.,


Kramer, M., & Stolzman, R. (1984). Six-month prevalence of psychiatric disorders in three communities. Archives of General Psychiatry, 41, 959-961.

Nordstrom, Cl., & Berglund, M. (1986). Successful adjustment in alcoholism: Relationships between causes of improvement, personality and social factors. Journal of Nervous and Mental Disease, 174, 664-668.

Parsons, O.A. (1987). Do neuropsychological deficits predict alcoholics’ treatment course and posttreatment recovery? In O.A. Parsons, N. Butters, & P.E. Nathan (Eds.), Neuropsychology of alcoholism: Implications for diagnosis and treatment (pp. 213- 290). New York: Guilford.

Poldrugo, F., & Forti, B. (1988). Personality disorders and alcoholism treatment outcome. Drug and Alcohol Dependence, 21, 171-176.

Powell, B.J., Penick, E.C., Othmer, E., Bingham, S.F., & Rice, A.F. (1982). Prevalence of additional psychiatric syndromes among male alcoholics. Journal of Clinical Psychiatry, 43, 404-407.

Robins, L.N., Helzer, J.E., Weissman, M.M., Orvaschel, H., Gruenberg, E., Burke, J.D., & Regier, D.A. (1984). Lifetime prevalence of specific psychiatric disorders in three sites. Ar- chives of General Psychiatry, 41, 949-958.

Rounsaville, B.J., Dolinsky, Z.S., Babor, T.F., & Meyer, R.E. (1987). Psychopathology as a predictor of treatment outcome in alcoholics. Archives of General Psychiatry, 44, 505-513.

Rounsaville, B.J., & Kleber, H.D. (1986). Psychiatric disorders in opiate addicts: Preliminary findings on the course and interac- tion with program type. In R.E. Meyer (Ed.), Psychopathology and addictive disorders (pp. 140-168). New York: Guilford.

Schneider, R., & Googins, B. (1989). Alcoholism day treatment: Ra- tionale, research and resistance. Journal of Drug Issues, 19, 437-449.

Schuckit, M.A. (1972). The alcoholic woman: A literature review. Psychiatry in Medicine, 3, 37-43.

Schuckit, M.A. (1985). The clinical implications of primary diagnostic groups among alcoholics. Archives of General Psychiatry, 42, 1043-1049.

Schuckit, M.A. (1986). Genetic and clinical implications of alcoholism and affective disorder. American Journal of Psychiatry, 143, 140-147.

Schuckit, M.A., & Morrissey, E.R. (1976). Alcoholism in women: Some clinical and social perspectives with an emphasis on pos- sible subtypes. In M. Greenblatt & M.A. Schuckit (Eds.), Alco- holism problems in women and children (pp. 5-35). New York: Grune and Stratton.

Schuckit, M.A., Pitts, F.N., Reich, T., King, L.J., & Winokur, G. (1969). Alcoholism: Two types of alcoholism in women. Ar- chives of General Psychiatry, 20, 301-306.

Shapiro, D. (1965). Neurotic styles. New York: Basic Books. Shelton, M.D., Parsons, O.A., Leber, W.R., & Yohman, J.R.

(1982). Locus of control and neuropsychological performance in chronic alcoholics. Journal of Clinical Psychology, 38,649-655.

Stall, R., & Biernacki, P. (1986). Spontaneous remission from the problematic use of substances: An inductive model derived from a comparative analysis of the alcohol, opiate, tobacco and food/obesity literatures. International Journal of the Addictions, 21, l-23.

Thoreson, R.W., Budd, F.C., & Krauskopf, C.J. (1986). Alcohol- ism among psychologists: Factors in relapse and recovery. Pro- fessional Psychology: Research and Practice, 17, 497-503.

Tuchfield, B.S. (1981). Spontaneous remission in alcoholics: Empir- ical observations and theoretical implications. Journal of Studies on Alcohol, 42, 626-641.

U.S. Department of Health and Human Services. (1987). Sixth special report to the U.S. Congress on alcohol and health (DHHS Publication Number ADM 87-1519). Washington, DC: U.S. Government Printing Office.

Vygotsky, L. (1962). Thought and language. Cambridge, MA: MIT Press.

Weisman, M.M., Meyers, J.K., & Harding, P.S. (1980). Prevalence and psychiatric heterogeneity of alcoholism in a United States urban community. Journal of Studies on Alcohol, 41,672-681.

Werner, E.E. (1986). Resilient offspring of alcoholics: A longitudi- nal study from birth to age 18. Journal of Studies on Alcohol, 47, 34-40.

Winokur, Cl., Rimmer, J., & Reich, T. (1971). Alcoholism: IV. Is there more than one type of alcoholism? British Journal of Psy- chiatry, 118, 525-53 1.

Documents

Predicting relapse and recovery in alcoholism and addiction: Neuropsychology, personality, and cognitive style