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An early counselling intervention program for problem drinkers contrasting group and individual delivery.. Adams, Douglas R. 1990

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AN EARLY COUNSELLING INTERVENTION PROGRAM FOR PROBLEM DRINKERS CONTRASTING GROUP AND INDIVIDUAL DELIVERY FORMATS by DOUGLAS R. ADAMS B.A., University of British Columbia, 1972 M.A., University of British Columbia, 1978 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF THE DOCTOR OF EDUCATION in THE FACULTY OF GRADUATE STUDIES • in the Department of COUNSELLING PSYCHOLOGY THE UNIVERSITY OF BRITISH COLUMBIA 1990 (§) Douglas Ronald Adams, 1990 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of C o u n s e l l i n g Psychology The University of British Columbia Vancouver, Canada D a t e a r ^-i i i n , lgqn DE-6 (2788) ABSTRACT I t i s h y p o t h e s i z e d t h a t group t r e a t m e n t may be more e f f e c t i v e t h a n an i n d i v i d u a l t r e a t m e n t f o r m a t . The p u r p o s e o f t h i s s t u d y was t o a d d r e s s s e v e r a l d e f i c i e n c i e s o f p r e v i o u s r e s e a r c h i n c o n t r a s t i n g group and i n d i v i d u a l t r e a t m e n t d e l i v e r y formats and t o a s s e s s t h e d i f f e r e n t i a l e f f e c t i v e n e s s o f t h e s e two f o r m a t s . The t r e a t m e n t a r e a c h o s e n was t h a t o f e a r l y p r o b l e m d r i n k e r t r e a t m e n t as i t was r e l a t i v e l y easy t o c o n t r o l t r e a t m e n t c o n t e n t a c r o s s t r e a t m e n t formats s i n c e d e t a i l e d c o n t e n t manuals and t h e o r y have been w e l l d e v e l o p e d i n t h i s a r e a . S u b j e c t s were s e l e c t e d from t h o s e r e s p o n d e n t s t o a media a d v e r t i s e m e n t who p a s s e d s e v e r a l s c r e e n i n g c r i t e r i a and were a l t e r n a t e l y a s s i g n e d t o a group o r i n d i v i d u a l f o r m a t . A l a c k o f t h e r e q u i s i t e number o f s u b j e c t s r e q u i r e d some s p e c i f i c d e s i g n changes . E a c h t r e a t m e n t c o n d i t i o n was g i v e n a s t r u c t u r e d e i g h t - w e e k t r e a t m e n t program o f once p e r week meet ings o f s e v e n t y - f i v e m i n u t e s e a c h o r a w a i t - l i s t c o n t r o l c o n d i t i o n . S t a t i s t i c a l c o n t r a s t s were t h e n p e r f o r m e d on t h e f o l l o w i n g v a r i a b l e s : t o t a l d r i n k u n i t s p e r week, maximum d r i n k u n i t s p e r d a y , P r o f i l e o f Mood S t a t e s - a measure o f c u r r e n t a f f e c t i v e s t a t e , Weissman S o c i a l A d j u s t m e n t S c a l e - a measure o f s o c i a l f u n c t i o n i n g l e v e l , and a g e n e r a l p r o b l e m c h e c k l i s t . Data u n i t s were g a t h e r e d \ I p r e - t r e a t m e n t , week ly d u r i n g t r e a t m e n t f o r d r i n k u n i t s , a t p o s t - t r e a t m e n t f o l l o w - u p , and a t s i x months f o l l o w i n g t h e end o f t r e a t m e n t . The o t h e r d a t a were g a t h e r e d p r e - t r e a t m e n t , p o s t - t r e a t m e n t , and a t t h e s i x - m o n t h f o l l o w - u p . R e s u l t s o f t h e d a t a m a n i p u l a t i o n s i n d i c a t e d t h a t the t r e a t m e n t i n t e r v e n t i o n was a s s o c i a t e d w i t h g r e a t e r improvement on a l c o h o l consumpt ions t h a n a w a i t - l i s t c o n t r o l g r o u p , b u t t h a t group t r e a t m e n t was n o t a s s o c i a t e d w i t h g r e a t e r t r e a t m e n t g a i n s t h a n t h e i n d i v i d u a l format on any m e a s u r e s . These r e s u l t s a r e g i v e n t o be t e n t a t i v e g i v e n s e v e r a l m a j o r l i m i t a t i o n s o f t h i s s t u d y w h i c h a r e d i s c u s s e d . The r e s e a r c h was found t o be r e l e v a n t i n t h e a r e a o f t r e a t m e n t p l a n n i n g , and i s i n t e r p r e t e d as p r o v i d i n g a more t h e o r e t i c a l l y m e a n i n g f u l c o n t r a s t o f t h e two formats t h a n p r e v i o u s l y a c h i e v e d due t o g r e a t e r e x p e r i m e n t a l c o n t r o l o f p o s s i b l y c o n f o u n d i n g v a r i a b l e s . A u s e f u l i n i t i a l t e s t was p e r f o r m e d o f a t r e a t m e n t program d e v e l o p e d f o r t h i s s t u d y w h i c h shows p r o m i s e f o r h e l p i n g p r o b l e m d r i n k e r s . I t i s a l s o s u g g e s t e d t h a t t h i s r e s e a r c h p r o v i d e s some i m p o r t a n t c o n c l u s i o n s f o r t h e c o n t r a s t o f g r o u p and i n d i v i d u a l f o r m a t s i n p s y c h o l o g i c a l i n t e r v e n t i o n s g e n e r a l l y . F u t u r e d i r e c t i o n s a r e s u g g e s t e d . TABLE OF CONTENTS A b s t r a c t H T a b l e o f C o n t e n t s '- , V « L i s t o f T a b l e s , . . , VI.. » » t L i s t o f F i g u r e s V"L C h a p t e r 1 I n t r o d u c t i o n 1 C h a p t e r 2 L i t e r a t u r e Review 5 S e v e r i t y o f Problems 5 Review o f R e l e v a n t D r i n k R e d u c t i o n T r e a t m e n t S t u d i e s 8 C o n t r a s t s o f Group and I n d i v i d u a l T r e a t m e n t o f P r e - A l c o h o l i c s 18 Summary and C o n c l u s i o n s from t h e L i t e r a t u r e on Groups f o r Prob lem D r i n k e r s 28 A r e a s o f H e a l t h R e q u i r i n g Assessment i n I n t e r v e n t i o n s w i t h Prob lem D r i n k e r s 3 0 Added Impact o f t h e Group Treatment F o r m a t : S o c i a l P s y c h o l o g i c a l R e s e a r c h 3 3 Models o f Group I n f l u e n c e 3 4 Models P r o p o s e d by S o c i a l P s y c h o l o g y t o U n d e r s t a n d Group I n f l u e n c e 47 A p p l i e d S o c i a l P s y c h o l o g y and Group I n f l u e n c e s . . . 52 Group v e r s u s I n d i v i d u a l Format 57 T h e r a p e u t i c F a c t o r s and Group T r e a t m e n t . 60 F a c t o r s U n i q u e t o I n d i v i d u a l Treatment 71 Summary o f R e l e v a n t F i n d i n g s 75 C o n c l u s i o n 81 Purpose and H y p o t h e s i s 82 C h a p t e r 3 Methodo logy 85 Overv iew 85 E x p e r i m e n t a l D e s i g n 8 5 S u b j e c t s 88 P o p u l a t i o n Samples 88 R e c r u i t m e n t and S e l e c t i o n 88 T h e r a p i s t s 90 P r o c e d u r e 9 0 Trea tment C o n d i t i o n s 9 0 Review o f D e s i g n 92 C o n t a c t and S e l e c t i o n o f C l i e n t s . 92 Random Ass ignment 9 4 C o l l a t e r a l V e r i f i c a t i o n by S i g n i f i c a n t O t h e r s 94 I V D e s i g n A d j u s t m e n t s . . . . . 95 S t a t i s t i c a l C o n s i d e r a t i o n s . . . . 96 M a t e r i a l s 99 The T r e a t m e n t Program 99 S c r e e n i n g Measures 118 Dependent Measures 120 A l c o h o l Consumpt ion 120 L i f e S a t i s f a c t i o n Q u e s t i o n n a i r e 121 P r o f i l e o f Mood S t a t e s 122 Weissman S o c i a l Adjus tment S c a l e 123 C h a p t e r 4 R e s u l t s 125 S e c t i o n One: D e s c r i p t i v e S t a t i s t i c s 125 S e c t i o n Two: P o s t - T e s t S t a t i s t i c a l C o n t r a s t s . . . . 138 ( i ) C o n t r a s t s T e s t i n g H y p o t h e s i s One 139 ( i i ) C o n t r a s t s T e s t i n g H y p o t h e s i s T w o . . . . . . . 148 C h a p t e r 5 D i s c u s s i o n . 162 Review o f Hypotheses and C o n c l u s i o n s 162 H y p o t h e s i s One 163 H y p o t h e s i s Two 164 L i m i t a t i o n s o f t h i s S t u d y 166 I m p l i c a t i o n s o f t h i s S tudy f o r C o u n s e l i n g T r e a t m e n t Formats 176 I m p l i c a t i o n s o f t h i s S tudy f o r F u t u r e R e s e a r c h 179 S u g g e s t i o n s f o r F u t u r e R e s e a r c h 182 Summary 18 6 B i b l i o g r a p h y 188 A p p e n d i x A M e d i c a l S c r e e n i n g 201 A p p e n d i x B A d v e r t i s e m e n t 204 A p p e n d i x C C l i e n t Consent Form 205 Append ix D The V a l i d i t y o f S e l f - R e p o r t Data 206 A p p e n d i x E C l i e n t S e l f - M o n i t o r i n g C a r d . . . 221 A p p e n d i x F M i c h i g a n A l c o h o l i s m S c r e e n i n g T e s t 222 Append ix G The L i f e S a t i s f a c t i o n Q u e s t i o n n a i r e . . . . 2 2 4 A p p e n d i x H The P r o f i l e o f Mood S t a t e s 22 6 A p p e n d i x I S o c i a l Adjus tment S c a l e - S e l f R e p o r t . . . . 227 V L I S T OF TABLES T a b l e 1 C h a r a c t e r i s t i c s o f C l i e n t s i n Group and I n d i v i d u a l T r e a t m e n t : H y p o t h e s i s 1. S o c i a l and Demographic 12 6 T a b l e 2 C h a r a c t e r i s t i c s o f C l i e n t s i n Group and I n d i v i d u a l T r e a t m e n t : H y p o t h e s i s 1. A l c o h o l Consumpt ion and R e l a t e d P r e - T e s t Measures 12 8 T a b l e 3 C h a r a c t e r i s t i c s o f C l i e n t s i n Treatment and W a i t - L i s t G r o u p s : H y p o t h e s i s 2. S o c i a l and Demographic 131 T a b l e 4 C h a r a c t e r i s t i c s o f C l i e n t s i n Treatment and W a i t - L i s t G r o u p s . H y p o t h e s i s 2. A l c o h o l Consumption and R e l a t e d P r e - t e s t Measures 13 2 T a b l e 5 Nominal Demographic Data f o r E n t i r e S tudy Sample 134 T a b l e 6 R a t i o Demographic Data f o r E n t i r e Study Sample 134 t T a b l e 7 H y p o t h e s i s One: P o s t - t e s t A n a l y s i s o f C o v a r i a n c e Compar i sons t o A s s e s s S i m i l a r i t y o f S u b - g r o u p s 14 0 T a b l e 8 H y p o t h e s i s One: P o s t - t e s t A n a l y s i s o f C o v a r i a n c e Compar i sons t o A s s e s s S i m i l a r i t y o f S u b - g r o u p s p r e v i o u s l y W a i t - l i s t e d and n o t P r e v i o u s l y W a i t - l i s t e d o f the I n d i v i d u a l Trea tment C o n d i t i o n 14 2 T a b l e 9(a) M a j o r C o n t r a s t s o f H y p o t h e s i s One: A n a l y s i s o f C o v a r i a n c e C o n t r a s t s Between Group T r e a t m e n t and I n d i v i d u a l T r e a t m e n t . P o s t - t e s t 144 T a b l e 9(b) M a j o r C o n t r a s t s Between Group Trea tment and I n d i v i d u a l T r e a t m e n t . S i x Month F o l l o w - u p . . . . 145 T a b l e 10 H y p o t h e s i s Two: P o s t - T e s t A n a l y s i s o f C o v a r i a n c e Compar i sons t o A s s e s s S i m i l a r i t y o f S u b - g r o u p s (w i th t h o s e p r e v i o u s l y on W a i t - l i s t d e l e t e d ) . Group One and Group Two o f t h e Group T r e a t m e n t C o n d i t i o n 150 T a b l e 11 P o s t - t e s t A n a l y s i s o f C o v a r i a n c e t o A s s e s s S i m i l a r i t y o f S u b - g r o u p s , Group Trea tment and I n d i v i d u a l T r e a t m e n t S u b j e c t s 152 T a b l e 12 M a j o r C o n t r a s t s o f H y p o t h e s i s Two: A n a l y s i s o f C o v a r i a n c e C o n t r a s t s Between T r e a t e d and W a i t - l i s t C o n t r o l S u b j e c t s (w i th s u b j e c t s p r e v i o u s l y on W a i t - l i s t d e l e t e d from t h e t r e a t e d s u b j e c t p o o l ) 154 T a b l e 13(a) Means and S t a n d a r d D e v i a t i o n s f o r t h e T h r e e C o n d i t i o n s on P o s t - t r e a t m e n t Weekly A l c o h o l Consumpt ion 156 T a b l e 13(b) A n a l y s i s o f V a r i a n c e f o r t h e T h r e e C o n d i t i o n s on P o s t - T r e a t m e n t Weekly Consumption 157 T a b l e 13(c) O r t h o g o n a l C o n t r a s t s o f C o n d i t i o n s on P o s t - Trea tment Weekly Consumption 157 T a b l e 14(a) Means and S t a n d a r d D e v i a t i o n s f o r t h e T h r e e C o n d i t i o n s on P o s t - t r e a t m e n t Peak Day A l c o h o l , Consumpt ion 158 T a b l e 14(b) A n a l y s i s o f V a r i a n c e f o r t h e T h r e e C o n d i t i o n s on P o s t - T r e a t m e n t Peak Day A l c o h o l Consumpt ion 158 T a b l e 14(c) O r t h o g o n a l C o n t r a s t s o f C o n d i t i o n s on P o s t - Trea tment Peak Day Consumption 159 VII L I S T OF FIGURES Page F i g u r e 1 H i s t o r i c a l D e s c r i p t i o n o f t h e O v e r a l l P r o c e d u r e 98 F i g u r e 2 I n t e r v e n t i o n s U t i l i z e d and When These Were Used 103 F i g u r e 3 Weekly consumpt ion 147 VHI CHAPTER 1 AN EARLY COUNSELLING INTERVENTION PROGRAM FOR PROBLEM DRINKERS CONTRASTING GROUP AND INDIVIDUAL DELIVERY FORMATS The f i e l d o f c o u n s e l i n g p s y c h o l o g y s e t s as i t s aim the p r o m o t i o n o f h e a l t h , w e l l - b e i n g , and p e r s o n a l development so t h a t each i n d i v i d u a l may r e a c h h i s o r h e r own p o t e n t i a l ( E r i k s o n and W h i t e l y , 1980; Ivey and Simek-Downing, 1980) . A major impediment t o a l i f e o f h e a l t h , w e l l - b e i n g and a c t u a l i z e d p o t e n t i a l i s t h e i n t e r f e r e n c e o f a d d i c t i o n s , one o f the most w i d e - s p r e a d and d e s t r u c t i v e o f which i n v o l v e s o v e r c o n s u m p t i o n o f a l c o h o l . S i n c e c o u n s e l i n g p s y c h o l o g y seeks t o a s s i s t p e o p l e i n overcoming problems so t h a t they may l i v e more complete l i v e s , i t seems i m p o r t a n t t h a t the f i e l d t u r n i t s a t t e n t i o n s t o the problem o f o v e r c o n s u m p t i o n o f a l c o h o l . Many t r e a t m e n t d e s i g n s and modes o f d e l i v e r y have been sugges ted t o a s s i s t prob lem d r i n k - e r s . However, t h e d i f f i c u l t y i s t h a t t h e r e a r e no 1 c l e a r i n d i c a t i o n s o f which d e s i g n s and modes w i l l be t h e most e f f e c t i v e . The c u r r e n t s t u d y has been c o n s t r u c t e d t o e x p l o r e t h i s p r o b l e m more f u l l y and i n v e s t i g a t e s the compara- t i v e e f f e c t i v e n e s s o f group and i n d i v i d u a l c o u n s e l i n g t r e a t m e n t s f o r problem d r i n k e r s . A d e f i n i t i v e s t u d y i n t h e a r e a c o u l d have an impact on t h e d e s i g n and d e l i v - e r y o f f u t u r e t r e a t m e n t f o r m a t s . S t r u c t u r e d t r e a t m e n t programs based on c o g n i t i v e b e h a v i o r a l p r i n c i p l e s have r e c e n t l y been d e v e l o p e d and have p r o v e n t o be s u c c e s s f u l i n t h e a r e a s o f we ight c o n t r o l , .smoking c e s s a t i o n , and a l c o h o l consumpt ion r e d u c t i o n . P r i o r t o the development o f s t r u c t u r e d t r e a t m e n t s , s t u d i e s c o n t r a s t i n g group and i n d i v i d u a l format were p l a g u e d by m e t h o d o l o g i c a l p r o b l e m s , t h e most p e r s i s t e n t o f which was the i n a b i l i t y t o s e p a r a t e format and c o n t e n t . As a r e s u l t , group and i n d i v i d u a l t r e a t m e n t s i n p r e v i o u s c o n t r a s t s d i f f e r e d i n b o t h format and c o n t e n t , making i t i m p o s s i b l e t o i s o l a t e format as a v a r i a b l e . The development o f s t r u c t u r e d t r e a t m e n t s has e n a b l e d the c o n t r o l o f c o n t e n t . 2 C o n s e q u e n t l y , a r e t u r n t o t h e q u e s t i o n o f the compara- t i v e impact o f group and i n d i v i d u a l formats becomes s i g n i f i c a n t a t t h i s t i m e . Some c u r r e n t s u g g e s t i o n s a r e t h a t group and i n d i v i d u a l formats are e q u a l l y e f f e c t i v e . However, p r o p o n e n t s o f group methods ( e . g . Yalom, 1975; N a t a l i and C v i t i k o v i c , 1977) would argue t h a t group d e l i v e r y adds u n i q u e and p o w e r f u l f e a t u r e s r e s u l t i n g i n a g r e a t e r and more e n d u r i n g t r e a t m e n t impac t . In a d d i - t i o n , s o c i a l p s y c h o l o g i s t s ( e . g . A s c h , 1952) p r o v i d e d a t a which i m p l i e s t h a t a group format c o u l d be more i m p a c t f u l t h a n an i n d i v i d u a l f o r m a t . R e s e a r c h t o date on the c o m p a r a t i v e e f f i c a c y o f group v e r s u s i n d i v i d u a l t r e a t m e n t p r e s e n t a t i o n i n the a l c o h o l consumpt ion r e d u c t i o n a r e a i s r e l e v a n t but f l a w e d . Two hypotheses were i n v e s t i g a t e d i n the p r e s e n t s t u d y . The p r i m a r y h y p o t h e s i s examined i n t h i s s t u d y i s t h a t a group format i s more e f f e c t i v e t h a n an i n d i v i d u a l f o r m a t , showing g r e a t e r change on the t a r g e t 3 b e h a v i o r o f d r i n k r e d u c t i o n . T h i s h y p o t h e s i s i s based on a s o c i a l l e a r n i n g model o f group communicat ion and t r e a t m e n t . A second h y p o t h e s i s i s t h a t t r e a t m e n t u t i l i z i n g a s t r u c t u r e d p s y c h o e d u c a t i o n a l program i s s u p e r i o r t o n o - t r e a t m e n t . The hypotheses were t e s t e d u s i n g a s t r u c t u r e d t r e a t m e n t program f o r problem d r i n k e r s , the g o a l o f w h i c h was t o r e d u c e the consumption o f a l c o h o l . The e f f i c a c y o f the hypotheses were a s se s sed by c o n t r a s t i n g d r i n k consumpt ion f i g u r e s between group , i n d i v i d u a l , and w a i t - l i s t c o n d i t i o n s as a major c o n t r a s t , and o t h e r h e a l t h r e l a t e d measures as a minor c o n t r a s t . 4 CHAPTER 2 LITERATURE REVIEW S e v e r i t y o f D r i n k i n g Problems The e p i d e m i c n a t u r e o f a l c o h o l problems has been w e l l documented. I t has been e s t i m a t e d t h a t s e v e n - t y - f i v e p e r c e n t o f a d u l t Canadians consume a l c o h o l , and t h a t one i n t e n o f these i s a problem d r i n k e r whose o v e r - i n v o l v e m e n t w i t h d r i n k i n g i s c a u s i n g o n - g o i n g problems <in h i s o r h e r l i f e . T h i s e s t i m a t e may be low by h a l f g i v e n a r e c e n t s tudy (Saxe e t a l . , 1983) . A l c o h o l problems are a f a c t o r i n 80% o f a l l p o l i c e a r r e s t s and a r e s i g n i f i c a n t l y i n v o l v e d i n m a r i t a l and f a m i l y d i s c o r d . F i f t y p e r c e n t o f m a r i t a l d i s r u p t i o n s , domes t i c v i o l e n c e and i n c e s t , are r e l a t e d t o c o n t i n u e d a l c o h o l abuse , as a r e one t h i r d o f a l l c a s e s o f c h i l d a b u s e . ( A D E S , 1978) . 5 A d d i t i o n a l l y , a l c o h o l abuse i s i n v o l v e d i n a v a r i e t y o f o t h e r problems . F u l l y t w e n t y - f i v e p e r c e n t o f t h e c h i l d r e n o f a l c o h o l i c s become a l c o h o l i c them- s e l v e s (McKenna and P i c k e n s , 1981) . C a l d e r and K o s t y n i u k (1989) found t h a t c h i l d r e n o f a l c o h o l i c s were o v e r r e p r e s e n t e d f o u r t imes the expec ted amount i n the c l i n i c a l range o f a c h i l d p e r s o n a l i t y s c a l e , a l t h o u g h about h a l f o f the c h i l d r e n o f a l c o h o l i c s had no c l i n i - c a l e l e v a t i o n s . E l e v a t i o n s were p a r t i c u l a r l y l i k e l y on a s u b s c a l e o f f a m i l y r e l a t i o n s , f o l l o w e d by d e l i n q u e n - c y , d e p r e s s i o n and w i t h d r a w a l . T h i s f o l l o w s common c l i n i c a l p e r c e p t i o n s . In a d d i t i o n t o t h e s e e f f e c t s , t h e c o s t t o i n d u s t r y i s enormous, e s t i m a t e d i n Canada t o be 21 m i l l i o n d o l l a r s each day i n l o w e r e d p r o d u c t i v - i t y , a c c i d e n t s , and s i c k l e a v e (Canada, 1981) . A l c o h o l and i t s r e l a t e d prob lems , e x c l u d i n g i t s i n v o l v e m e n t i n h e a r t d i s e a s e (which i s c o n s i d e r a b l e ) , c a n c e r and h o m i c i d e s , i s the f o u r t h l e a d i n g cause o f d e a t h (ADES, 1978) . Between t h i r t y and f i f t y p e r c e n t o f h o s p i t a l a d m i s s i o n s i n the U . S . are a t t r i b u t a b l e t o a l c o h o l i s m (Saxe e t a l . , 1983) . Saxe a l s o no ted t h a t o v e r h a l f t h e a l c o h o l consumption i s c a r r i e d out by l e s s t h a n t e n p e r c e n t o f t h e d r i n k i n g p o p u l a t i o n . However, f u l l y 85% 6 o f a l l a l c o h o l i c s (the a p p r o x i m a t e l y h a l f o f prob lem d r i n k e r s who a r e t r u e a l c o h o l a d d i c t s i n t h a t they s u f f e r w i t h d r a w a l when d e p r i v e d o f a l c o h o l ( K i s s i n , 1977)) n e v e r r e c e i v e any t rea tment f o r a l c o h o l i s m . C r u z e t a l . (1977) have r e c e n t l y c o m p i l e d a monumental a n a l y s i s o f the c o s t s o f a l c o h o l prob lems and t r e a t m e n t s . In t h e i r e s t i m a t i o n o f c o s t s they c o n s i d e r e d t h e f o l l o w i n g f a c t o r s : d i r e c t t r e a t m e n t , s u p p o r t s u c h as r e s e a r c h and e d u c a t i o n , l o s t p r o d u c t i v - i t y due t o e a r l y d e a t h , i m p a i r e d p r o d u c t i v i t y , m i s s e d work t i m e and f a i l e d employment, v e h i c l e c r a s h e s and i n j u r i e s , c r i m i n a l c o s t s , w e l f a r e c o s t s , o t h e r c o s t s such as f . i r e , d e c r e a s e d i n d i r e c t p r o d u c t i v i t y t ime due t o i n c a r c e r a t i o n and v e h i c l e c r a s h e s . They d i d no t e s t i m a t e f a m i l y c o s t s , o r second g e n e r a t i o n a l c o h o l and p s y c h o l o g i c a l prob lems , which a r e p r o p o s e d t o be s i g n i f i c a n t and s e v e r e . The t o t a l c o s t s e s t i m a t e d by C r u z e t a l . numbered 49 b i l l i o n d o l l a r s i n t h e U . S . i n 1977. T h i s s u r p a s s e d the B e r r y e t . a l . (1977) f i g u r e o f 40 b i l l i o n d o l l a r s but i s c l a i m e d t o be low by C r u z e t a l . , c i t i n g S c h i f r i n e t a l . (1975) who e s t i m a t e d t h e c o s t s a t 60 b i l l i o n , p a r t l y due t o an u n d e r e s t i m a t i o n 7 i n each c a t e g o r y by B e r r y and p a r t l y due t o f a m i l y c o s t s which B e r r y l e f t o u t . Saxe e t a l . (1983) p r o j e c t s t h e s e f i g u r e s i n t o 1983 d o l l a r s t o y i e l d a c o s t o f a l c o h o l problems and t r e a t m e n t r a n g i n g from 72 b i l l i o n t o 120 b i l l i o n p e r y e a r . Thus i t i s c l e a r t h a t a l c o h o l abuse i s a major p r o b l e m . Programs d e s i g n e d t o h e l p c o n t a i n t h i s prob lem t h u s become i m p o r t a n t f i e l d s o f i n v e s t i g a t i o n . Review o f D r i n k R e d u c t i o n Treatment S t u d i e s A r e l a t i v e l y l a r g e body o f r e s e a r c h e x i s t s on s t r u c t u r e d t r e a t m e n t s d e s i g n e d t o reduce a l c o h o l c o n s u m p t i o n . P a t t i s o n , S o b e l l , and S o b e l l (1977) l i s t s e v e n t e e n s t u d i e s w i t h a c o n t r o l l e d d r i n k i n g g o a l and a f u r t h e r f i f t y - s e v e n i n which c o n t r o l l e d d r i n k i n g i s an outcome. M i l l e r and H e s t e r (1980) r e p o r t an a d d i t i o n a l t e n b r i n g i n g t o t w e n t y - s e v e n t h e number o f s t u d i e s h a v i n g c o n t r o l l e d d r i n k i n g as a g o a l . Most o f t h e s e s t u d i e s r e f e r t o a l c o h o l a d d i c t s who show a p h y s i c a l dependency on a l c o h o l marked by w i t h - d r a w a l o r a b s t i n e n c e syndrome when a l c o h o l i s no l o n g e r 8 a v a i l a b l e . S e v e r a l r e s e a r c h e r s have c o n c l u d e d t h a t a more f a v o r a b l e p r o g n o s i s e x i s t s when problem d r i n k i n g i s l e s s s e r i o u s , l e s s l o n g l a s t i n g and i n v o l v e s lower g e n e r a l consumpt ion (Baekland & L u n d w a l l , 1975; O r f o r d , 1973; M i l l e r and J o y c e , 1979; V o g l e r e t a l . , 1977) . Thus most r e c e n t s t u d i e s have g e n e r a l l y s e l e c t e d n o n - a d d i c t e d prob lem d r i n k e r s f o r s u b j e c t s . The f o l l o w i n g s t u d i e s were completed u s i n g n o n - a d d i c t e d p r o b l e m d r i n k e r s (a s i m i l a r sample a l s o s e r v e d as c l i e n t s i n the c u r r e n t s t u d y ) . Most r e c e n t s t u d i e s d i d n o t u t i l i z e group t r e a t m e n t and thus these s t u d i e s w i l l o n l y be rev i ewed where some a s p e c t r e l a t e s t o t h e c u r r e n t s t u d y . A u s e f u l rev iew o f most o f t h e s t u d i e s i n t h e a r e a can be found i n Heather & R o b e r t s o n (1981) . The r e l e v a n t s t u d i e s o n l y are r e p o r t e d and d i s c u s s e d be low. The f i r s t s t u d y c o n s i d e r e d was conducted by Pomer leau e t a l . (1978) who c o n t r a s t e d " t r a d i t i o n a l " g r o u p t h e r a p y and b e h a v i o r a l group t r e a t m e n t . S u b j e c t s were m i d d l e - c l a s s on average , had s t a b l e m a r r i a g e s , j o b s and good h e a l t h . There were 46 r e f e r r a l s w i t h an average age o f 44 y e a r s and an average a l c o h o l - r e l a t e d 9 p r o b l e m d u r a t i o n o f e i g h t y e a r s . Seven s u b j e c t s were d i v e r t e d and r e f e r r e d f o r t rea tment e l sewhere because o f s e v e r i t y o f p s y c h o l o g i c a l problems o r d e p r e s s i o n , and a f u r t h e r seven d e c l i n e d t o a t t e n d the f i r s t p o s t - s c r e e n i n g appointment . An o b j e c t i o n might w e l l be made t o t h e p r o c e d u r e o f r e j e c t i n g s u b j e c t s due t o p r o n e n e s s t o d e p r e s s i o n (4 s u b j e c t s ) s i n c e d e p r e s s i o n i s endemic t o the p o p u l a t i o n o f t h o s e who have problems w i t h a l c o h o l (Baek land , 1977). The r e m a i n i n g 32 s u b j e c t s , w i t h a mean p r e - s c r e e n i n g consumption o f 57 (S tandard D r i n k U n i t s ) p e r week, were randomly a s s i g n e d t o groups o f 6 o r 7 s u b j e c t s each i n one o f the two c o n d i t i o n s . I t s h o u l d be no ted t h a t t h i s consumption i s among the h i g h e s t i n s t u d i e s o f problem d r i n k e r s . The groups met f o r 1.5 h o u r s p e r week f o r 3 months w i t h 5 a d d i t i o n a l b o o s t e r s e s s i o n s a f t e r c o m p l e t i o n o f t r e a t m e n t . W h i l e l a u d a b l e e f f o r t s were made t o keep t h e two t r e a t m e n t samples s e p a r a t e , the methodology a l s o , u n f o r t u n a t e l y , i n c l u d e d a s s i g n i n g t h e f o u r t h e r a p i s t s e x c l u s i v e l y t o one c o n d i t i o n o r t h e o t h e r . T h u s , 10 t h e r a p i s t s t y l e o r e f f e c t i v e n e s s i s confounded w i t h t r e a t m e n t methodology. D i f f e r e n t i a l t h e r a p i s t e f f e c - t i v e n e s s may have i n f l u e n c e d the outcome, o b s c u r i n g o t h e r d i f f e r e n c e s . The b e h a v i o r a l t reatment group u t i l i z e d s e v e r a l s e p a r a t e p r o c e d u r e s , one o f which was t h e d e p o s i t i n g o f a sum o f money t o be earned back a t i n t e r v a l s f o r t r e a t m e n t a t t e n d a n c e . T h i s approach f o l l o w s common b e h a v i o r m o d i f i c a t i o n p r o c e d u r e s as used i n a v a r i e t y o f d i f f e r e n t i n t e r v e n t i o n s (eg. Tharp and W e t z e l , 1969; B o u d i n , 1972; L e i b s o n , 1972; D i R i s i & B u t z , 1975) . S u c c e s s o f t h i s t e c h n i q u e w i t h i n the g e n e r a l a r e a o f c o n t i n g e n c y c o n t r a c t i n g has been f a i r l y w e l l e s t a b - l i s h e d w i t h o t h e r p r e s e n t i n g p r o b l e m s . However, H e a t h e r and R o b e r t s o n (1981) c r i t i c i z e t h i s s t u d y f o r t h e use o f money i n t h i s f a s h i o n , s i n c e t h e t r a d i t i o n a l group t r e a t m e n t d i d not use money c o n t i n g e n t l y . T h i s use o f money may w e l l have i n f l u e n c e d t h e r e s u l t s , however i t i s c o n s i s t e n t w i t h b e h a v i o r t r e a t m e n t p r i n c i p l e s and thus seems t o be an a p p r o p r i a t e i n t e r - v e n t i o n and t h e r e f o r e the Heather and R o b e r t s o n c r i t i - c i s m seems u n j u s t i f i e d . 11 L i k e t h e b e h a v i o r a l g r o u p t r e a t m e n t , t h e t r a d i - t i o n a l l y o r i e n t e d g r o u p t r e a t m e n t a l s o r e q u i r e d p a y - m e n t , b u t t h i s was d o n e p r i o r t o e a c h s e s s i o n a n d n o r e f u n d s f o r c o m p l i a n c e w e r e g i v e n . T h e m o d e l was b a s e d o n a n i n s i g h t - o r i e n t e d a p p r o a c h e m p h a s i z i n g t h e d e v e l - o p m e n t o f i n t e n s e g r o u p c o h e s i o n , c o n f r o n t a t i o n o f d e n i a l , a n d t h e m o t i v a t i o n o f t h e c l i e n t s t o w a r d p o s i t i v e g o a l s . I n d i v i d u a l p s y c h o t h e r a p y was p r o v i d e d a s n e e d e d b u t n o t d e f i n e d i n t h e r e p o r t , a s t o f r e q u e n - c y , c o n t e n t , o r d i f f e r e n t i a l e f f e c t . W h i l e i n c o m p l e t i o n a n d f o l l o w - u p t h e r e w e r e f o u n d t o b e no s i g n i f i c a n t d i f f e r e n c e s b e t w e e n t h e t w o t r e a t m e n t * g r o u p s , t h e a u t h o r s c o n c l u d e t h a t t h e b e h a v - i o r a l t r e a t m e n t was t h e m o r e s u c c e s s f u l . T h i s c o n c l u - s i o n i s b a s e d o n t h e s i g n i f i c a n t c o n s u m p t i o n d e c r e a s e b e t w e e n p r e - t e s t a n d p o s t - t e s t i n t h e b e h a v i o r a l c o n d i t i o n o n l y a s w e l l a s o n t h e w i d e d i f f e r e n c e i n d r o p - o u t r a t e s . R e g a r d i n g t h e d i f f e r e n t i a l d r o p - o u t r a t e f i r s t , 4 3% o f t h e t r a d i t i o n a l g r o u p members d r o p p e d o u t p r i o r t o p o s t - t e s t c o m p a r e d t o 11% f r o m t h e b e h a v i o r a l 12 c o n d i t i o n . Pomerleau e t a l . (1978) a t t r i b u t e d the d r o p - o u t r a t e d i f f e r e n c e t o the g r e a t e r i n t e n s i t y and c o n f r o n t a t i o n o f the t r a d i t i o n a l t r e a t m e n t , p o i n t i n g o u t t h a t a l l b u t one d r o p - o u t o c c u r r e d a t t h e 8 th o r 9 t h week o f t r e a t m e n t , c o i n c i d i n g w i t h "the c u l m i n a t i o n o f i n t e n s e i n t e r p e r s o n a l c o n f r o n t a t i o n s i n t h e r a p y " (p. 198) . An o b j e c t i o n t o u s i n g d i f f e r e n t i a l d r o p - o u t r a t e as a measure o f t r ea tment s u c c e s s i s t h a t , c l e a r l y , d i f f i c u l t i e s e x i s t e d i n the p r e s e n t a t i o n o f the t r a d i - t i o n a l t r e a t m e n t which d e t r a c t e d from t h e v a l i d i t y o f t h e e n t i r e c o n t r a s t . S e c o n d l y , the use made o f change s c o r e s i n t h i s s t u d y seems s u s p e c t . D i f f e r e n c e s between t r e a t - ments a r e based on p r e - t e s t d i f f e r e n c e s which were t h e n a s s o c i a t e d w i t h d i f f e r e n t change s c o r e s between the c o n d i t i o n s o v e r the c o u r s e o f t r e a t m e n t t o r e s u l t i n s i m i l a r p o s t - t e s t s c o r e s . The o b j e c t i o n made h e r e i s t h a t t h e samples were i n i t i a l l y d i f f e r e n t enough from each o t h e r t h a t compar i sons on t r e a t m e n t v a r i a b l e s may w e l l n o t be v a l i d . 13 However, i n s p i t e o f t h e above noted f l a w s , the p o s t - t e s t r e s u l t s p r o v i d e e v i d e n c e t h a t a b e h a v i o r a l group t r e a t m e n t i s e q u a l l y as e f f e c t i v e as a t r a d i t i o n - a l g r o u p . Perhaps t h i s i s because many o f t h e group p r o c e s s f a c t o r s i d e n t i f i e d i n t r a d i t i o n a l groups (Yalom, 1975) c o u l d a l s o be expec ted t o o c c u r w i t h i n t h e b e h a v i o r a l g r o u p s . A l t h o u g h t h i s s t u d y i s not c o m p a r a t i v e w i t h r e g a r d t o group v e r s u s i n d i v i d u a l f o r m a t s , i t s u p p o r t s the e f f i c a c y o f group i n t e r v e n - t i o n s g e n e r a l l y f o r the t r e a t m e n t o f problem d r i n k e r s . A second s t u d y by O i e & J a c k s o n (1983) r e p o r t e d an i n p a t i e n t s t u d y u s i n g group formats w i t h a sample o f p r o b l e m d r i n k e r s who were a t the h i g h but p r e - a d d i c t i v e end o f consumpt ion and who were s e l e c t e d f o r low a s s e r t i v e n e s s . A l t h o u g h t h i s s tudy was no t c o m p a r a t i v e o f group v e r s u s i n d i v i d u a l formats i t p r o v i d e s some u s e f u l s u g g e s t i o n s r e g a r d i n g the g e n e r a l u t i l i t y o f group i n t e r v e n t i o n s . The c o n d i t i o n s compared i n t h i s s t u d y were: (1) s o c i a l s k i l l s t r a i n i n g , (2) c o g n i t i v e r e s t r u c t u r i n g , (3) a c o m b i n a t i o n t r e a t m e n t , and (4) a minimum 14 t r e a t m e n t c o n t r o l g r o u p . A l l c o n d i t i o n s s i g n i f i c a n t l y d e c r e a s e d consumpt ion by p o s t - t e s t . However, the c o n t r o l / m i n i m a l t r e a t m e n t c o n d i t i o n s u b j e c t s soon r e v e r t e d t o the p r e v i o u s l e v e l s o f consumption w h i l e t h e o t h e r c o n d i t i o n s u b j e c t s remained a t a low consump- t i o n l e v e l . The c o m b i n a t i o n t rea tment c o n d i t i o n m a i n t a i n e d low consumption even a y e a r l a t e r . The a u t h o r s c o n c l u d e d t h a t c o g n i t i v e changes i n a t t i t u d e , b e l i e f s , and c o v e r t s e l f - i n s t r u c t i o n s brought about l o n g - l a s t i n g and , i n many c a s e s , c o n t i n u i n g i m p r o v e - ment. In g e n e r a l , t h i s s tudy s u p p o r t s the i d e a t h a t a group format may be a power fu l change agent . However, a c o n t r a s t o f group and i n d i v i d u a l format awa i t s f u r t h e r r e s e a r c h . In a t h i r d s t u d y o f p a r t i c u l a r r e l e v a n c e t o the a r e a , Murphy, Pagans, and M a r l a t t (1986) examined 60 heavy d r i n k e r s (45 d r i n k s o r more p e r month) who were randomly a s s i g n e d t o a s c h e d u l e o f e x e r c i s e ( r u n n i n g ) , m e d i t a t i o n , o r a n o - t r e a t m e n t c o n t r o l g r o u p . Due t o t h e impact o f d r o p p i n g out o f t r e a t m e n t o r d r o p p i n g out d u r i n g t h e s i x week f o l l o w - u p , t h e f i n a l numbers a t e a c h o f t r e a t m e n t c o m p l e t i o n and f o l l o w - u p r e s p e c t i v e l y 15 were: r u n n i n g (n = 13 and 9 ) , m e d i t a t i o n (n = 14 and 9 ) , and no t rea tment c o n t r o l (n = 13 and 6 ) . A l l groups s i g n i f i c a n t l y reduced a l c o h o l consumpt ion o v e r t h e c o u r s e o f t r ea tment and f o l l o w - u p . The r u n n i n g group was found t o have s i g n i f i c a n t l y lower consumpt ion t h a n t h e c o n t r o l group a t c o m p l e t i o n o f t r e a t m e n t , and t h e m e d i t a t i o n group outcomes f e l l between t h e r u n n i n g and t h e c o n t r o l g r o u p s . A t the s i x week f o l l o w - u p t h e c o n t r o l group and m e d i t a t i o n group consumpt ion had i n c r e a s e d a lmost t o b a s e l i n e w h i l e the r u n n i n g group i n c r e a s e d o n l y s l i g h t l y . The s i g n i f i c a n t t r e a t m e n t o v e r t i m e e f f e c t was found t o be a lmos t e n t i r e l y due t o t h e low consumpt ion o f those i n the r u n n i n g c o n d i t i o n . M e d i t a t i o n was much more e f f e c t i v e f o r h i g h c o m p i l e r s (5 .3 t i m e s p e r week o r more) than low c o m p i l e r s . Group i n f l u e n c e may have been a s i g n i f i c a n t f a c t o r i n change i n t h i s s t u d y . Murphy e t a l . (1986) sugges t i n t h e i r c o n c l u s i o n t h a t the i n c r e a s e d e f f e c t i v e n e s s o f t h e r u n n i n g c o n d i t i o n may have been due t o any o f t h e f o l l o w i n g : the i n d i v i d u a l i z e d r u n n i n g p l a n , p e e r s o c i a l s u p p o r t , o r the presence o f l e a d e r s who p r o v i d e d e n t h u s i a s m , f eedback , and r o l e - m o d e l i n g . Low c o m p i l e r s 16 i n m e d i t a t i o n , who reduced a l c o h o l consumpt ion by 24% as compared t o 60% r e d u c t i o n f o r h i g h c o m p i l e r s , were found t o a t t e n d group m e d i t a t i o n s e s s i o n s l e s s r e g u l a r - l y . Perhaps i t was t h e i r low a t t e n d a n c e which reduced t h o s e i n t e r p e r s o n a l i n f l u e n c e e f f e c t s which were p r e s e n t f o r the s u b j e c t s a t t e n d i n g t h e m e d i t a t i o n c o n d i t i o n . In f a c t , the a u t h o r s c o n j e c t u r e t h a t group p a r t i c - i p a t i o n , s o c i a l i n t e r a c t i o n o r p e e r s u p p o r t may have been a s s o c i a t e d w i t h the d e c r e a s e s i n consumpt ion and were more a v a i l a b l e t o r u n n e r s and t o a t t e n d e e s o f m e d i t a t i o n g r o u p s , b o t h o f whom showed t h e g r e a t e s t d e c r e a s e , in consumpt ion . T h i s s tudy o f f e r s t e n t a t i v e s u p p o r t , t h e r e f o r e , f o r the a d d i t i o n a l t h e r a p e u t i c impact t h a t may t h e o r e t i c a l l y be a c h i e v e d by use o f a group p r e s e n t a t i o n . T h u s , i t a p p e a r s , upon a r e v i e w o f r e l e v a n t s t u d i e s u t i l i z i n g group format w i t h n o n - a d d i c t e d p r o b l e m d r i n k e r s , t h a t group format o f f e r s p r o m i s e as an e f f e c t i v e means o f i n t e r v e n t i o n . In f a c t , t h e Murphy e t a l . s t u d y (1986) l e n d s some s u p p o r t t o the 17 i d e a t h a t some a s p e c t o f s o c i a l i n t e r a c t i o n may make a group t rea tment more p o w e r f u l . F u r t h e r r e v i e w o f s t u d i e s which u n d e r t o o k a more d i r e c t c o n t r a s t o f s o c i a l i n t e r a c t i o n format w i t h f o r m a t s l a c k i n g t h i s component i s r e q u i r e d . C o n t r a s t s o f Group and I n d i v i d u a l Trea tment o f P r e - A l c o h o l i c s In t h i s s e c t i o n an e x a m i n a t i o n i s made o f s e v e r a l s t u d i e s which d i r e c t l y c o n t r a s t e d group and i n d i v i d u a l f o r m a t s . The d i r e c t i o n s t h a t t h i s r e s e a r c h has p o i n t e d toward foa: f u t u r e development and drawbacks o f t h e r e s e a r c h t o date a r e d i s c u s s e d . T h e o r y and p r a c t i c e o f group p s y c h o t h e r a p y sugges t t h a t t h e r e are s e v e r a l un ique f a c t o r s t h a t s h o u l d add t o t r e a t m e n t e f f e c t i v e n e s s when group methods a r e a p p l i e d . U n f o r t u n a t e l y , w h i l e group t r e a t m e n t i s a common method o f i n t e r v e n t i o n w i t h the more s e v e r e a l c o h o l i c s , t h e r e i s l i t t l e i n the way o f r e s e a r c h a d d r e s s i n g the f a c t o r s and impact s un ique t o a group 18 a p p r o a c h w i t h t h i s p o p u l a t i o n . P a t t i s o n (1979) argues t h a t the l a c k o f d e s c r i p t i o n o f components o f the v a r i o u s group formats used w i t h a l c o h o l i c s makes c o n t r a s t s between them o r w i t h o t h e r formats meaning- l e s s . He notes t h a t , i n t h e t rea tment o f a l c o h o l i s m , " . . . g r o u p s a r e w i d e l y p r e f e r r e d . . . y e t t h e r e has b e e n . . . l i t t l e e m p i r i c a l e v i d e n c e t o s u p p o r t t h i s c h o i c e " (p. 158) . He s t a t e s t h a t " . . . c o n t r o l l e d s t u d i e s have p r o v i d e d no s u p p o r t f o r the p o p u l a r b e l i e f t h a t group methods r e p r e s e n t a s u p e r i o r approach" (p. 57) and c o n c l u d e s t h a t t h e wide mix o f t e c h n i q u e s used and the g e n e r a l l y p o o r d e s i g n s o f s t u d i e s i n t h i s a r e a p r e v e n t drawing g e n e r a l i m p l i c a t i o n s . S i m i l a r l y , t h e r e has been l i t t l e d i r e c t work compar ing group and i n d i v i d u a l formats w i t h n o n - a d d i c t - ed p r o b l e m d r i n k e r s . S i n c e a l c o h o l a d d i c t i o n t r e a t m e n t draws i t s predominant h i s t o r i c a l i n f l u e n c e from t h e c o n f e s s i o n a l - s u p p o r t format o f A l c o h o l i c s Anonymous, g r o u p s a r e a n a t u r a l outgrowth o f t h i s f o r m a t . I n c o n t r a s t , prob lem d r i n k e r t r e a t m e n t has been h e a v i l y dominated by b e h a v i o r a l / s o c i a l l e a r n i n g t h e o r i e s o f p r a c t i c e and formats o f t r e a t m e n t . H i s t o r i c a l l y , 19 i n d i v i d u a l approaches have been the norm h e r e . On t h o s e few o c c a s i o n s when a group format has been u t i l i z e d , t h e added component o f group membership has n o t been s p e c i f i c a l l y a s s e s s e d . Thus t h e q u e s t i o n r e m a i n s : what , i f a n y t h i n g would a group approach u n i q u e l y o f f e r t o the t rea tment o f prob lem d r i n k e r s ? R e s e a r c h i n c o n t r o l l e d d r i n k i n g t r e a t m e n t c o n - t r a s t i n g group and i n d i v i d u a l formats has been s p a r s e . T h e r e a r e , i n f a c t , o n l y two r e s e a r c h s t u d i e s t h a t d i r e c t l y a d d r e s s the e f f i c a c y o f a group t r e a t m e n t format f o r p r o b l e m d r i n k e r s i n c o n t r o l l e d d r i n k i n g p r o g r a m s . Both o f these appear f l a w e d . M i l l e r , Pechacek, & Hamburg (1981) conduc ted a s t u d y u s i n g a group p r e s e n t a t i o n w i t h t h e M i l l e r & Munoz manual (1982) f o r b e h a v i o r s e l f - c o n t r o l t r e a t - ment. One s t a t e d purpose o f d e v e l o p i n g a group format was " . . . b e c a u s e o f p o t e n t i a l b e n e f i t s a c c r u i n g from i n t e r a c t i o n s among c l i e n t s s h a r i n g t h i s problem" (p. 8 3 0 ) . T h u s , he s e t s out t o s p e c i f i c a l l y enhance t r e a t m e n t by a d d i n g the un ique f e a t u r e s o f a group f o r m a t . U n f o r t u n a t e l y , the r e s e a r c h d e s i g n was not 20 c a p a b l e o f r e f l e c t i n g any added impact o f a group f o r m a t . I n t h i s s tudy the s u b j e c t p o o l o f 28 (18 males) was r e c r u i t e d through media; c o l l a t e r a l v e r i f i c a t i o n was a v a i l a b l e f o r 22; mean i n t a k e consumpt ion was 43 d r i n k u n i t s p e r week. S u b j e c t s , on a v e r a g e , had e x p e r i e n c e d a l c o h o l r e l a t e d l i f e problems f o r 8.6 y e a r s , and had an average M i c h i g a n A l c o h o l i s m S c r e e n i n g T e s t (MAST) s c o r e o f 1 5 . 5 . The s u b j e c t s were a s s i g n e d t o one o f f o u r i d e n t i - c a l c l a s s e s , each w i t h a maximum c l i e n t s i z e o f t e n p l u s s i g n i f i c a n t o t h e r s i f they wished t o a t t e n d . The c o u r s e l a s t e d t e n weeks o f 1.5 hour s e s s i o n s w i t h one s e s s i o n a t the m i d - p o i n t a s s i g n e d f o r i n d i v i d u a l c o n s u l t a t i o n . The c l a s s o therwise f o l l o w e d the p r e s e n - t a t i o n o f m a t e r i a l i n the M i l l e r & Munoz book w i t h the f i r s t f i v e weeks d e d i c a t e d t o d r i n k i n g c o n t r o l by means o f g o a l s e t t i n g , d r i n k i n g r a t e c o n t r o l , s e l f - r e i n f o r c e - ment, s t i m u l u s c o n t r o l , and f u n c t i o n a l a n a l y s i s o f d r i n k i n g . The l a t t e r f o u r weeks o f f e r e d b e h a v i o r a l 21 a l t e r n a t i v e s : deep muscle r e l a x a t i o n , a s s e r t i v e n e s s and communicat ion s k i l l s , and a f i n a l assessment . T h i s s t u d y does no t p r e s e n t group p r o c e s s i n t h e t r a d i t i o n a l sense d e s c r i b e d by Yalom (1975) but r a t h e r p l a c e s c o n s i d e r a b l e r e s t r i c t i o n s on the emergence o f group p r o c e s s . M i l l e r e t a l . (1981), however, c l e a r l y i n t e n d e d t h a t group impact would be a b l e t o emerge i n t h i s f o r m a t . M i l l e r d e s c r i b e s the program as " . . . e d u - c a t i o n a l l y o r i e n t e d group therapy" (p. 837) but i t a p p e a r s from the d e s c r i p t i o n t h a t i t was more s i m i l a r t o an a l c o h o l e d u c a t i o n program i n which t h e r e was o n l y r e s t r i c t e d o p p o r t u n i t y f o r group i n t e r a c t i o n . i C l i e n t s c o m p l e t i n g t h e program showed s i g n i f i c a n t changes o v e r t rea tment and t h r o u g h t o t h r e e month f o l l o w - u p i n weekly consumpt ion o f a l c o h o l . Consump- t i o n a t c o m p l e t i o n and f o l l o w - u p d e c r e a s e d t o a p p r o x i - m a t e l y 25 d r i n k u n i t s p e r week (one d r i n k u n i t i s e q u a l t o one f o u r ounce g l a s s o f w i n e ) . Peak B . A . L . ( B l o o d A l c o h o l L e v e l ) per week, average B . A . L . , and number o f heavy d r i n k i n g days (5 d r i n k u n i t s o r more) l i k e w i s e d e c r e a s e d . 22 In h i s c o n c l u s i o n M i l l e r s t a t e s : "No d i r e c t c o m p a r i s o n o f group v e r s u s i n d i v i d u a l b e h a v i o r s e l f - c o n t r o l t r a i n i n g has been r e p o r t e d t o d a t e , however, and c o n c l u s i o n s r e g a r d i n g r e l a t i v e e f f i c a c y must a w a i t f u r t h e r r e s e a r c h " (p. 857) . S i n c e no c o n t r o l group o f a n o - t r e a t m e n t c o n d i t i o n o r an i n d i v i d u a l format t rea tment was u t i l i z e d i n t h i s s t u d y , no c o n c l u s i o n s on t h e c o m p a r a t i v e impacts o f t h e s e formats can be made. In t h e second r e l e v a n t s tudy M i l l e r & T a y l o r (1980) c o n t r a s t e d f o u r c o n d i t i o n s : a m a n u a l - o n l y m i n i m a l c o n t a c t c o n d i t i o n , b e h a v i o r s e l f - c o n t r o l t r a i n i n g , b e h a v i o r s e l f - c o n t r o l t r a i n i n g p l u s r e l a x a - t i o n t r a i n i n g , and a group format b e h a v i o r s e l f - c o n t r o l t r a i n i n g p l u s r e l a x a t i o n . The t r e a t m e n t was a g a i n d e r i v e d from the M i l l e r & Munoz (1982) manual . The group c o n d i t i o n i n t h i s s t u d y was t h e same c l a s s r o o m format used i n the p r e v i o u s s t u d y . S u b j e c t s were randomly a s s i g n e d t o the f i r s t t h r e e c o n d i t i o n s and the f i n a l twe lve a s s i g n e d non-randomly 23 t o t h e group c o n d i t i o n . An o b j e c t i o n t o the non-random ass ignment i n the group c o n d i t i o n i s t h a t t h e s u b j e c t s o f t h i s c o n d i t i o n may t h u s no t be c o m p a r a b l e . T h e r e were 41 s u b j e c t s (25 male) t r e a t e d , average age 45.4 y e a r s , w i t h a problem d u r a t i o n ( " . . . l i f e problems r e l a t e d t o a l c o h o l " ) o f 10.1 y e a r s , a mean MAST o f 1 8 . 5 , and a mean weekly i n t a k e consumpt ion o f 54.4 d r i n k u n i t s . T h i s i s a more s e r i o u s consumpt ion p a t t e r n than t h a t i n many o f the o t h e r prob lem d r i n k i n g r e s e a r c h programs r e v i e w e d . C o n d i t i o n one i n v o l v e d r e a d i n g and w o r k i n g t h r o u g h t h e manual w i t h v e r y l i t t l e t h e r a p i s t c o n t a c t . C o n d i - t i o n two i n v o l v e d w o r k i n g t h r o u g h t h e manual w i t h a t h e r a p i s t . C o n d i t i o n t h r e e was s i m i l a r t o c o n d i t i o n two w i t h the a d d i t i o n o f r e l a x a t i o n t r a i n i n g . C o n d i - t i o n f o u r was the group c o n d i t i o n which i n v o l v e d w o r k i n g t h r o u g h t h e manual w i t h a t h e r a p i s t and t h e n r e c e i v i n g r e l a x a t i o n t r a i n i n g . The purpose o f t h i s s t u d y was t o c a r r y out an i n v e s t i g a t i o n o f the e f f e c t s o f v a r i o u s t r e a t m e n t d e l i v e r y f o r m a t s . M i l l e r d i d not a d d r e s s the query he 24 p u t f o r w a r d i n h i s p r e v i o u s s tudy r e g a r d i n g ( " p o t e n t i a l b e n e f i t s a c c r u i n g from i n t e r a c t i o n s among c l i e n t s s h a r i n g t h i s prob lem" (p. 830) ( M i l l e r e t a l . , 1981) . R e s u l t s i n d i c a t e d t h a t consumption reduced s i g n i f - i c a n t l y a c r o s s t r e a t m e n t w i t h no s i g n i f i c a n t d i f f e r e n c - es between t r e a t m e n t s . A l l groups a l s o showed s i g n i f i - c a n t changes on l o c u s o f c o n t r o l and a mood measure ( P r o f i l e o f Mood S t a t e s ) , and 73% r e p o r t e d improvement i n l i f e problems w h i l e 19% r e p o r t e d d e t e r i o r a t i o n . Thus i t appears t h a t t h e r e was s i g n i f i c a n t and l o n g - l a s t i n g impact on d r i n k i n g . However i t i s a l s o n o t e d t h a t group and i n d i v i d u a l formats were e q u a l l y e f f e c t i v e . S e v e r a l c r i t i c i s m s o f t h i s s t u d y a r e n o t e d and w i l l be r e v i e w e d below. C o n d i t i o n t h r e e c o n s i s t e d o f t e n 50 minute s e s s i o n s w h i l e c o n d i t i o n f o u r c o n s i s t e d o f t e n 90 minute s e s s i o n s . Thus an o b j e c t i o n i s t h a t t r e a t m e n t format i s confounded w i t h t r e a t m e n t s e s s i o n d u r a t i o n . A second c r i t i c i s m i s t h a t t h e r a p i s t s f o r t h e f i r s t t h r e e c o n d i t i o n s were p a r a p r o f e s s i o n a l t r a i n e e s i n p s y c h o l o g y a t the u n d e r g r a d u a t e o r g r a d u a t e 25 l e v e l , and were d i s t r i b u t e d a c r o s s c l i e n t s i n each o f t h e t h r e e c o n d i t i o n s . The c o n d i t i o n f o u r t h e r a p i s t s were more h i g h l y t r a i n e d - i n f a c t t h e two a u t h o r s t h e m s e l v e s , b o t h u n i v e r s i t y f a c u l t y . A n o t h e r o b j e c t i o n emerges from t h i s i n t h a t s k i l l and s t y l e l e v e l s o f t h e r a p i s t s a r e confounded w i t h f o r m a t . A t h i r d c r i t i c i s m r e f e r s t o the f a c t t h a t s u b j e c t s were not randomly a s s i g n e d t o t h e group c o n d i t i o n w h i l e t h e y were randomly a s s i g n e d t o the o t h e r t h r e e c o n d i - t i o n s . Thus a s y s t e m a t i c b i a s may have been i n t r o d u c e d t o t h e d a t a by t h e methods o f t r e a t m e n t as s ignment . W i t h r e g a r d t o t h i s c r i t i c i s m i t needs t o be p o i n t e d o u t t h a t , 1 w h i l e consumption i n t h e v a r i o u s t r e a t m e n t c o n d i t i o n s a t c o m p l e t i o n and up t o one y e a r f o l l o w - u p were a p p r o x i m a t e l y e q u i v a l e n t a t about 16 and 22 d r i n k u n i t s r e s p e c t i v e l y , mean consumptions o f the t r e a t m e n t c o n d i t i o n s a t i n t a k e d i f f e r e d c o n s i d e r a b l y from each o t h e r . Consumption o f the b i b l i o t h e r a p y group appeared t o be h i g h e s t a t i n t a k e , the two i n d i v i d u a l s e l f - c o n - t r o l c o n d i t i o n s were i n the m i d d l e , and the group c o n d i t i o n was l o w e s t a t what appears from graphs p r e s e n t e d t o be 75, 50, and 30 d r i n k u n i t s e a c h . 26 Because o f t h i s wide i n i t i a l d i f f e r e n c e , compar i sons between t h e s e c o n d i t i o n s a r e l e s s m e a n i n g f u l . They appear t o be samples from d i f f e r e n t p o p u l a t i o n s . F o u r t h l y , t h e r e was a p e r s i s t e n t p r o b l e m o f d r o p - out o f s u b j e c t s w i t h the numbers r e p o r t i n g a t i n t a k e , c o m p l e t i o n , and t h r e e month f o l l o w - u p d e c l i n i n g from 41 t o 35 t o 21 . T h i s d r o p - o u t r a t e s e v e r e l y r e d u c e s the u t i l i t y o f the d a t a . A t f o l l o w - u p , d a t a i s m i s s i n g on 49% o f t h e s u b j e c t s . F i f t h l y , t h e s u b j e c t s o f t h i s s tudy as a whole , r e p r e s e n t e d g r e a t e r s e r i o u s n e s s o f prob lem d r i n k i n g t h a n i s common f o r t h i s a r e a o f r e s e a r c h , some a p p e a r - i n g c l e a r l y t o be i n the p h y s i c a l l y a d d i c t i v e range o f a l c o h o l i s m . P r e v i o u s r e s e a r c h has i n d i c a t e d t h a t such s u b j e c t s would be l e s s r e s p o n s i v e t o c o n t r o l l e d d r i n k - i n g t r e a t m e n t (Baek lund , 1977; O r f o r d , 1973; V o g l e r e t a l . , 1977; M i l l e r & J o y c e , 1979; P o l i c h e t a l . , 1980; O r f o r d & K e d d i e , 1986). D e s p i t e t h e s e c r i t i c i s m s t h e s t u d y has c o n s i d e r - a b l e v a l u e t o t h e c u r r e n t r e s e a r c h . A n o n - s i g n i f i c a n t 27 t r e n d emerged i n which the group c o n d i t i o n showed t h e h i g h e s t improvement r a t e s a c r o s s t rea tment and f o l - low-up ( M i l l e r & T a y l o r , 1980) . The a u t h o r s s t a t e : " i n d i v i d u a l improvement r a t i n g s and d r i n k e r c l a s s i f i c a - t i o n s appear t o modes t ly f a v o r group 4 (the group c o n d i t i o n ) " ( p . 2 2 ) . T h i s t r e n d h i n t s t h a t an advantage may be found i n group formats w i t h a w e l l - d e s i g n e d s t u d y . In summary, i t seems c l e a r t h a t the a p p r o p r i a t e - ness o f a group format i n t r e a t m e n t o f problem d r i n k e r s has not been a d e q u a t e l y t e s t e d . I t i s not known whether a w e l l d e v e l o p e d group approach would be b e t t e r t h a n an i n d i v i d u a l format , e q u i v a l e n t t o i n d i v i d u a l t r e a t m e n t , o r whether i t would be worse than an i n d i - v i d u a l f o r m a t . Summary and C o n c l u s i o n s from t h e L i t e r a t u r e on Groups F o r Problem D r i n k e r s S e v e r a l s t u d i e s were rev i ewed which u t i l i z e d group format i n the t r e a t m e n t o f e a r l y s t a g e prob lem 28 d r i n k e r s . S t u d i e s u s i n g groups were i n the m i n o r i t y o f s t u d i e s on t r e a t m e n t o f e a r l y prob lem d r i n k e r s r e p o r t e d t o d a t e . Those which have used a group f o r m a t , howev- e r , c e r t a i n l y s u p p o r t e d the e f f e c t i v e n e s s o f group i n t e r v e n t i o n s . C o n c e r n i n g t h e c e n t r a l p u r p o s e s o f the c u r r e n t s t u d y , the one exper iment which has c o n t r a s t e d group and i n d i v i d u a l formats found them t o be a p p r o x i m a t e l y e q u a l l y e f f e c t i v e , y e t t h e c o n t r a s t s were f lawed i n s e v e r a l i m p o r t a n t r e s p e c t s . The M i l l e r & T a y l o r (1980) s t u d y d i d not u t i l i z e random ass ignment f o r t h e group c o n d i t i o n , the t r e a t m e n t c o n d i t i o n s d i f f e r e d s i g n i f i - c a n t l y from one a n o t h e r on a l c o h o l consumpt ion i n p r e t e s t , f o l l o w - u p d a t a i s m i s s i n g on a p p r o x i m a t e l y h a l f o f the i n i t i a l s u b j e c t s , the t h e r a p i s t s were a t d i f f e r e n t s k i l l l e v e l s i n the group c o n d i t i o n v e r s u s t h e o t h e r c o n d i t i o n s , and the i n d i v i d u a l t r e a t m e n t c o n s i s t e d o f 8.3 t r e a t m e n t hours w h i l e t h e group c o n d i t i o n was 15 hours i n l e n g t h . M i n i m a l l y , a r e p l i c a t i o n o f t h e M i l l e r & T a y l o r (1980) s t u d y seems i n o r d e r , as a r e s u l t o f t h e s e 29 f l a w s . A d i f f e r e n t p o p u l a t i o n would be r e q u i r e d i n which p r e - t r e a t m e n t consumption i s s i m i l a r a c r o s s c o n d i t i o n s . Even more u s e f u l would be an e x t e n s i o n o f t h e s t u d y which ensured s a t i s f a c t i o n o f the f o l l o w i n g c o n d i t i o n s : f i r s t t h a t ass ignment o f s u b j e c t s t o c o n d i t i o n s i s random, second t h a t the same t h e r a p i s t s a r e used i n a l l t r e a t m e n t s , t h i r d t h a t t r e a t m e n t l e n g t h i s e q u i v a l e n t a c r o s s c o n d i t i o n s , and f o u r t h and most i m p o r t a n t t h a t a group format w i t h i n c r e a s e d o p p o r t u n i - t y f o r member i n t e r a c t i o n be f a c i l i t a t e d . A r e a s o f H e a l t h R e q u i r i n g Assessment i n I n t e r v e n t i o n s With Problem D r i n k e r s An a r e a o f c o n c e r n i n r e s e a r c h o f a l c o h o l abuse r e l a t e s t o t h e tendency t o focus on a l c o h o l consumpt ion a l o n e . P a t t i s o n (1979) recommends s t r o n g l y t h a t f i v e s e p a r a t e a r e a s o f h e a l t h be c o n s i d e r e d i n t h e t r e a t m e n t o f t h o s e w i t h a l c o h o l p r o b l e m s . These a r e : d r i n k i n g h e a l t h , e m o t i o n a l h e a l t h , i n t e r p e r s o n a l h e a l t h , v o c a - t i o n a l h e a l t h , and p h y s i c a l h e a l t h . O n l y one o f t h e s e i s d i r e c t l y c o n c e r n e d w i t h a l c o h o l consumpt ion . The main t h r u s t o f P a t t i s o n ' s recommendation i s t h a t t r u l y 30 b e n e f i c i a l t r e a t m e n t w i l l impact p o s i t i v e l y on many a r e a s o f p e r c e i v e d maladjustment i n a d d i t i o n t o d r i n k - i n g . G e r a r d e t a l . (1962) found t h a t t h i s was no t a lways t h e c a s e . In t h e i r s t u d y they f o l l o w e d a group who had been s u c c e s s f u l l y a b s t i n e n t f o r a t l e a s t one y e a r . U s i n g i n t e r v i e w and p s y c h o l o g i c a l t e s t s t h e y found 10% o f t h i s sample t o be f u l l y f u n c t i o n i n g s u c c e s s e s . A f u r t h e r 23% they termed " A . A . successes" and no ted t h a t these had l i t t l e o r no s o c i a l l i f e o u t s i d e A l c o h o l i c s Anonymous. The a u t h o r s found a n o t h e r 25% t o be c o n s p i c u o u s l y i n a d e q u a t e ; l e a d i n g e x t r e m e l y "meager l i v e s " . A d i s t r e s s i n g 54% were d i a g n o s e d as o v e r t l y d i s t u r b e d . G e r a r d & Saenger (1966) f o l l o w e d t h i s s t u d y w i t h r e s e a r c h t h a t e s t i m a t e d t h a t between 12% and 32% o f t h o s e whose d r i n k i n g improved f u n c t i o n e d p o o r l y , and some f u n c t i o n e d even worse than p r i o r t o d r i n k i n g improvement on s e v e r a l o t h e r a r e a s o f h e a l t h . M i l l e r , H e d r i c k , & T a y l o r (1983) c a r r i e d out a f o l l o w - u p o f two c o n t r o l l e d d r i n k i n g s t u d i e s w i t h e a r l y p r o b l e m d r i n k e r s . E i g h t y - t w o t r e a t e d c l i e n t s and 31 e l e v e n d r o p - o u t s were a s se s sed on a range o f l i f e prob lems b e f o r e and a f t e r t r e a t m e n t . The program p r i m a r i l y f o c u s e d on a l c o h o l consumption management, a l t h o u g h i t a l s o i n c l u d e d two subgroups whose t r e a t m e n t had d e a l t w i t h o t h e r l i f e problems i n a d d i t i o n . S u b j e c t s were a s se s sed a t t h r e e t o s i x months, t w e l v e months, and t w e n t y - f o u r months p o s t - t r e a t m e n t . Those who comple ted t rea tment r e p o r t e d improvement on 75% o f a s s e s s e d l i f e problems a f t e r t r e a t m e n t , a l e v e l m a i n - t a i n e d o v e r t h e next two y e a r s . F o l l o w - u p a t t r i t i o n s were e x c l u d e d and not c l a s s i f i e d as d e t e r i o r a t e d . T h e r e was no d i f f e r e n c e found i n l i f e prob lem i m p r o v e - ment between a l c o h o l - f o c u s e d t rea tment s u b j e c t s and t h o s e who had e x p e r i e n c e d a b r o a d e r t r e a t m e n t a p p r o a c h . A n o t a b l e e x c e p t i o n was t h a t those s u b j e c t s whose a d d i t i o n a l t r e a t m e n t modules were i n d i v i d u a l i z e d t o t h e i r own u n i q u e t r e a t m e n t needs appeared t o show even g r e a t e r improvement. In summary, the above s t u d i e s i n d i c a t e t h e i m p o r - t a n c e o f o f f e r i n g t rea tment and a s s e s s i n g p r o g r e s s i n a l l a r e a s o f h e a l t h , not j u s t i n a l c o h o l c o n s u m p t i o n . Thus i t seems t o be v e r y i m p o r t a n t i n e v a l u a t i n g t h e 32 e f f i c a c y o f an a l c o h o l t r e a t m e n t program t o ensure t h a t t h e s e o t h e r areas o f l i f e o r h e a l t h prob lem be a s s e s s e d f o r t r e a t m e n t impact . Added Impact o f the Group Treatment Format: S o c i a l P s y c h o l o g i c a l R e s e a r c h G e n e r a l T h e o r e t i c a l S t u d i e s R e s e a r c h i n s o c i a l p s y c h o l o g y has had c o n s i d e r a b l e impact on c l i n i c a l and c o u n s e l i n g p s y c h o l o g y p r a c t i c e ( S t r o n g , 1978; Dorn , 1984) . H a r a r i (1983), r e f l e c t i n g on the importance o f s o c i a l p s y c h o l o g i c a l r e s e a r c h f o r t h e r a p e u t i c i n t e r v e n t i o n s , has c a l l e d f o r s p e c i f i c a p p l i e d s o c i a l p s y c h o l o g i c a l r e s e a r c h on c l i n i c a l p r a c t i c e . W h i l e t h i s has been e s s e n t i a l l y l a c k i n g t o d a t e , i t i s r e l e v a n t toward t h a t end t o r e v i e w a r e a s o f s o c i a l p s y c h o l o g i c a l r e s e a r c h t h a t may have i m p l i c a - t i o n s , t h r o u g h t h e o r y and e m p i r i c a l outcome, t o the c u r r e n t r e s e a r c h q u e s t i o n s . A c c o r d i n g l y , i t i s h e l p f u l t o rev i ew t h e l i t e r a - t u r e i n s o c i a l p s y c h o l o g y f o r s t u d i e s and t h e o r e t i c a l d i s c u s s i o n s t h a t would sugges t a d i f f e r e n t i a l impact o f 33 t r e a t m e n t s d e l i v e r e d i n a group v e r s u s an i n d i v i d u a l f o r m a t . The f o l l o w i n g s e c t i o n has been d i v i d e d i n t o two p a r t s . The f i r s t d i s c u s s e s t h e o r y which s u p p o r t s the h y p o t h e s i s t h a t t h e p r e s e n c e o f o t h e r s has a s p e c i f i c and u n i q u e i n f l u e n c e on p e r c e p t i o n and d e c i s i o n m a k i n g . The major f i n d i n g s o f A s c h , F e s t i n g e r , and W a l l a c h and Kogan and t h e i r c o l l e a g u e s are c o n s i d e r e d r e l e v a n t t o t h e c u r r e n t s t u d y and a r e d i s c u s s e d below. The a u t h o r s s t u d y the impact o f group i n t e r a c t i o n s on i n d i v i d u a l b e h a v i o r . They i n d i c a t e i n some d e t a i l how i n d i v i d u a l s may be s y s t e m a t i c a l l y i n f l u e n c e d i n s e l e c t e d d i r e c t i o n s by p e e r i n t e r a c t i o n . The second s e c t i o n d i s c u s s e s some o f the s p e c i f i c a p p l i e d s o c i a l p s y c h o l o g y r e s e a r c h r e g a r d i n g t h e impact o f s o c i a l i n f l u e n c e on s u b s t a n c e abuse . Mode l s o f Group I n f l u e n c e A s c h (1952) r e p o r t s a s e r i e s o f s t u d i e s r e l a t e d t o t h e impact o f p e e r s on p e r c e p t i o n s . R e c a l l i n g an e a r l i e r s tudy by Moore i n 1921, A s c h notes t h a t he was 34 i n t r i g u e d by M o o r e ' s f i n d i n g s t h a t t h e o p i n i o n o f o t h e r s d r a m a t i c a l l y a f f e c t e d s u b j e c t i v e judgments i n r e l a t i o n t o grammar, e t h i c s , and m u s i c . I n d i v i d u a l s were f i r s t asked t o make judgments i n t h e s e a r e a s . The s u b j e c t s were t h e n t o l d t h a t the m a j o r i t y o f p e o p l e had p r e v i o u s l y chosen the o p p o s i t e r e s p o n s e . The s u b j e c t s were t h e n r e - t e s t e d on the same t a s k . A l a r g e s h i f t t o t h e o p p o s i t e judgment was found on the r e t e s t . I t appeared e v i d e n t t h a t judgments were i n d e e d a f f e c t e d by p e e r s . A s c h a l s o r e p o r t e d an exper iment by S h e r i f i n 1935 i n w h i c h i n d i v i d u a l s made judgments about the r e l a t i v e a p p a r e n t movement o f a p o i n t o f l i g h t , a common a u t o k i n e t i c o p t i c a l i l l u s i o n which i s e n t i r e l y s u b j e c - t i v e . When s u b j e c t s a r e asked t o make judgment i n the p r e s e n c e o f o t h e r s , S h e r i f no ted t h a t t h e i r judgments s u c c e s s i v e l y approx imated each o t h e r o v e r t i m e . A s c h r e p o r t e d t h a t S p e r l i n g , i n a 1946 u n p u b l i s h e d r e p l i c a - t i o n and e x t e n s i o n o f S h e r i f s e x p e r i m e n t , p l a c e d p a i r s o f s u b j e c t s t o g e t h e r , one o f whom was i n s t r u c t e d t o a c t as a c o n f e d e r a t e o f t h e e x p e r i m e n t e r . S p e r l i n g found t h a t t h e judgments o f the n a i v e s u b j e c t were i n d e e d 35 a f f e c t e d by t h e c o n f e d e r a t e , and s h i f t e d somewhat i n t h a t d i r e c t i o n b u t not as f a r as those o f the c o n f e d e r - a t e . However, S p e r l i n g noted t h a t t h i s e f f e c t was t e m p o r a r y . Most n a i v e s u b j e c t s began d e n i g r a t i n g the c o n f e d e r a t e ' s judgment and they abandoned t h e i r t e n d e n - c y toward e x a g g e r a t i o n . Asch c r i t i c i z e d M o o r e ' s , S p e r l i n g ' s and S h e r i f s s t u d i e s f o r u t i l i z i n g a s i t u a - t i o n i n which o b j e c t i v i t y o f judgment was d i f f i c u l t , t h u s hamper ing t h e c l a r i t y o f the p e e r i n f l u e n c e e f f e c t . A s c h r e s o l v e d t h i s d i f f i c u l t y by s e l e c t i n g a n o n - s u b j e c t i v e t a s k i n v o l v i n g judgment o f l i n e l e n g t h s i n which - subjec t s were asked t o choose a l i n e e q u a l i n l e n g t h t o a g i v e n s t a n d a r d from t h r e e a l t e r n a t i v e s , one o f which was f a i r l y a p p a r e n t l y the c o r r e c t answer. He c o n s t r u c t e d g r o u p s o f seven t o n i n e c o n f e d e r a t e s and one n a i v e s u b j e c t s i n c e " . . . s m a l l e r g r o u p s , (he) f e a r e d , would l a c k the r e q u i s i t e ' g r o u p v o l u m e ' " (P. 455, A s c h , 1952) . The n a i v e s u b j e c t p r e s e n t e d h i s p u b l i c judgment a f t e r most o f the c o n f e d e r a t e s . D u r i n g t h e i n i t i a l t r i a l s , the c o n f e d e r a t e s p r e s e n t e d a c c u r a t e p u b l i c judgments i n agreement w i t h t h e p u b l i c 36 judgment o f the n a i v e s u b j e c t . On f u r t h e r t r i a l s t h e y p r e s e n t e d c o n s i s t e n t and i n a c c u r a t e judgments on s e v e r a l c r i t i c a l t r i a l s . N a ive s u b j e c t s responded by e x h i b i t i n g many s h i f t s toward agreement w i t h the m a j o r i t y i n a c c u r a t e judgment. Upon d e b r i e f i n g , s u b j e c t s (even those who made few s h i f t s toward the m a j o r i t y ) r e v e a l e d t h a t they e x p e r i - enced s e v e r e d i s c o m f o r t upon r e a l i z i n g t h a t t h e i r judgments r a n c o n t r a r y t o those o f the m a j o r i t y and t h a t t h e y were unable t o a v o i d p u b l i c l y p r o c l a i m i n g a judgment . They began t o doubt t h e i r own p e r c e p t i o n s , and were m o t i v a t e d t o a v o i d a p p e a r i n g d i f f e r e n t , o d d , o r no t a member o f the g r o u p . A s c h sugges t s t h a t t h e i r p r e v i o u s comfor t i n b e i n g a c o n s i s t e n t member o f a g r o u p was t h r e a t e n e d and hence t h e n a i v e members worked t o reduce t h e i r growing a l i e n a t i o n and p e r c e p t i o n o f t h e m s e l v e s as " . . i n f e r i o r . . " , " . . d i f f e r e n t . . " , o r " . . o u t c a s t . . " (P. 465 A s c h , 1952) . A s c h t h e n p r e s e n t e d some v a r i a t i o n s on the o r i g i - n a l e x p e r i m e n t . In the f i r s t e x t e n s i o n he i n c r e a s e d t h e magni tude o f the i n a c c u r a c y o f the m a j o r i t y 37 judgment . There was a s l i g h t i n c r e a s e i n t h e number o f i n d i v i d u a l s who remained independent i n t h e i r p u b l i c judgments but the t r e n d o f s h i f t s i n judgments toward agreement w i t h the m a j o r i t y d i d not d e c r e a s e . T h i s r e s u l t runs c o n t r a r y t o the f i n d i n g o f d e c r e a s e d s h i f t s w i t h g r e a t e r magnitude r e p o r t e d by S h e r i f . In a second e x t e n s i o n A s c h reduced the s i z e o f t h e group t o one n a i v e s u b j e c t and one c o n f e d e r a t e . The i n f l u e n c e o f t h i s m a n i p u l a t i o n was t o a lmos t t o t a l l y e r a d i c a t e t h e impact o f c o n f e d e r a t e ' s judgments on t h o s e o f the n a i v e s u b j e c t . In d e b r i e f i n g , a l t h o u g h n a i v e s u b j e c t s r e p o r t e d t h a t t h e y e x p e r i e n c e d some d i s t u r b a n c e a t the d i s c r e p a n c y , they r a r e l y s h i f t e d i n t h e i r p u b l i c judgments . T h i s i s s i m i l a r t o the r e s u l t s r e p o r t e d by S p e r l i n g . A t h i r d v a r i a t i o n was t o i n t r o d u c e a c o n f e d e r a t e i n the seven t o n i n e member groups who would p e r s i s t i n g i v i n g a c c u r a t e judgments , i n c o n t r a s t t o the o t h e r c o n f e d e r a t e s i n a c c u r a t e judgments . In t h i s c o n d i t i o n t h e s h i f t o f the n a i v e s u b j e c t s was reduced by h a l f . 38 In a f o u r t h m a n i p u l a t i o n , one i n a c c u r a t e c o n f e d e r - a t e was i n c l u d e d i n a group o f n a i v e s u b j e c t s . W h i l e t h i s r e s u l t e d i n no s h i f t s o f judgments i n t h e n a i v e s u b j e c t s , i t d i d r e s u l t i n c o n s i d e r a b l e d e r i s i o n , l a u g h t e r , and open contempt toward the c o n f e d e r a t e . T h i s seems, i n f a c t , t o e x e m p l i f y p r e c i s e l y t h e s i t u a - t i o n which the one n a i v e s u b j e c t would have a n t i c i p a t e d w i t h f e a r i n t h e o r i g i n a l exper iment and w h i c h l i k e l y m o t i v a t e d h i s judgment changes . A f i f t h m a n i p u l a t i o n u t i l i z e d e q u a l s i z e d s u b - group o f n a i v e s u b j e c t s and c o n f e d e r a t e s and r e s u l t e d i n no s h i f t i n judgments and few i n s t a n c e s o f d e r i s i o n . I t appears t h a t t h e n a i v e s u b j e c t s found s u f f i c i e n t p e e r s u p p o r t t o m a i n t a i n t h e i r i n i t i a l s t a n c e . In f u r t h e r i n v e s t i g a t i o n o f the A s c h p a r a d i g m M o s c o v i c i and Personnaz (1980) found t h a t , c o n t r a r y t o e x p e c t a t i o n , a m i n o r i t y i n f l u e n c e when c o n s i s t e n t o v e r s e v e r a l t r i a l s , c o u l d a l s o a f f e c t d e c i s i o n s . The a u t h o r s sugges ted t h a t a l t h o u g h m a j o r i t y i n f l u e n c e m o t i v a t e d c o m p l i a n c e by engag ing a need t o appear 39 c o n s i s t e n t w i t h a p p a r e n t l y v a l i d p e e r s , i n p u b l i c , t h i s i n f l u e n c e was l i m i t e d to t h e p u b l i c s p h e r e . However, t h e i n f l u e n c e o f a c o n s i s t e n t m i n o r i t y , w h i l e h a v i n g l i t t l e impact on p u b l i c r e s p o n s e , appeared t o r e s u l t i n a s i g n i f i c a n t s h i f t o f i n t e r n a l l y h e l d p e r c e p t i o n s and b e l i e f s , wh ich c o u l d then be d e t e c t e d as a c t e d out i n t h e p r i v a t e s p h e r e . A f t e r c o n t r a d i c t o r y r e s u l t s were found by two o t h e r r e s e a r c h teams Personnaz (1981) r e p l i c a t e d the o r i g i n a l M o s c o v i c i & Personnaz (1980) s t u d y and f o u n d , c o n s i s t e n t w i t h o r i g i n a l r e s u l t s , t h a t p e r c e p t u a l m o d i f i c a t i o n was a s s o c i a t e d w i t h the m i n o r i t y c o n d i t i o n b u t not t h e m a j o r i t y c o n d i t i o n , whereas c o m p l i a n c e was a s s o c i a t e d w i t h t h e m a j o r i t y c o n d i t i o n but n o t t h e m i n o r i t y c o n d i t i o n . Mugny (1984) , i n a p a r t i a l r e p l i c a t i o n o f t h e above s t u d y , found d i r e c t and i n d i r e c t i n f l u e n c e i n b o t h the m a j o r i t y and the m i n o r i t y c o n d i t i o n i f s u b - j e c t s b e l i e v e d t h a t they were t a k i n g p a r t i n an e x p e r i - ment t o s t u d y i l l u s i o n s . Presumably t h i s b e l i e f p e r m i t t e d l e s s r i g i d i t y o r a b s o l u t e n e s s i n t h e i r 40 r e s p o n s e s . W h i l e t h i s r e c a l l s the c r i t i c i s m o f f e r e d by A s c h t o t h e Moore , S h e r i f and S p e r l i n g s t u d i e s i n t h a t t h e t a s k becomes more s u b j e c t i v e , i t i s v a l u a b l e t o n o t e t h a t b o t h m a j o r i t y and m i n o r i t y i n f l u e n c e s c l e a r l y e f f e c t judgment . T h i s s e r i e s o f exper iments i s i m p o r t a n t i n r e f e r - ence t o t h e c u r r e n t s tudy i n t h a t i t emphasizes t h e impact o f a group o f p e e r s on an i n d i v i d u a l ' s b e h a v i o r . I t i s c o n s i s t e n t w i t h the r e s u l t s o f the above s t u d i e s t o e x t r a p o l a t e t h a t , i n a group i n which members share o b j e c t i v e d a t a r e g a r d i n g t h e impact o f t r e a t m e n t on t h e i r d r i n k i n g b e h a v i o r , i t i s more l i k e l y t h a t , over c o n s e c u t i v e p u b l i c s t a t e m e n t s , the members w i l l s u c c e s - s i v e l y a p p r o x i m a t e each o t h e r ' s performance i n the d i r e c t i o n o f p r e - s e t g o a l s . O t h e r s o c i a l p s y c h o l o g i s t s have s t u d i e d changes i n a t t i t u d e s , b e l i e f s and v a l u e s , i n the c o n t e x t o f peer i n f l u e n c e . F e s t i n g e r ( F e s t i n g e r & C a r l s m i t h , 1959) c a r r i e d o u t a s e r i e s o f s t u d i e s i n which i n d i v i d u a l s were asked t o p u b l i c l y e x p r e s s an a t t i t u d e c o n t r a r y t o a p r e v i o u s l y h e l d a t t i t u d e f o r e i t h e r a l a r g e o r s m a l l 41 monetary r e w a r d . Those who s t a t e d t h e c o n t r a r y a t t i - t u d e f o r a s m a l l r eward , i f the s ta tement c o s t them c o n s i d e r a b l e p e r s o n a l e f f o r t , tended t h e r e a f t e r t o embrace t h e c o n t r a r y a t t i t u d e r a t h e r t h a n t h e i r p r e v i - ous one . On the o t h e r hand, those who s t a t e d a c o n - t r a r y a t t i t u d e f o r a l a r g e reward tended a f t e r w a r d t o r e j e c t t h i s a t t i t u d e i n f a v o r o f t h e i r p r e v i o u s l y h e l d p o s i t i o n . F e s t i n g e r c o n j e c t u r e d t h a t t h e s u b j e c t s who r e c e i v e d t h e l a r g e r amount o f money c o u l d s t a t e a c o n t r a r y a t t i t u d e w i t h o u t d i s c o m f o r t by r a t i o n a l i z i n g t h a t t h e reward was l a r g e enough t o l e g i t i m i z e s t a t i n g a f a l s e a t t i t u d e , and t h a t they d i d n o t then o r s u b s e - q u e n t l y b e l i e v e the s t a t e d a t t i t u d e . Those who s t a t e d t h e f a l s e a t t i t u d e f o r o n l y s l i g h t reward c o u l d not r e f e r t o t h e amount o f the r e i n f o r c e m e n t t o l e g i t i m i z e t h e i r b e h a v i o r and were found l a t e r t o u t t e r a t t i t u d e s c o n s i s t e n t w i t h the p u b l i c l y s t a t e d a t t i t u d e r a t h e r t h a n t h e i r p r e v i o u s l y h e l d a t t i t u d e . These i n d i v i d u a l s had r e s o l v e d the f e l t d i s s o n a n c e o f t h e i r s t a t e d p o s i t i o n v e r s u s h i s p r e v i o u s l y h e l d p o s i t i o n by a l t e r - i n g t h e i r p r e v i o u s l y h e l d a t t i t u d e t o be c o n s i s t e n t w i t h t h e i r p u b l i c b e h a v i o r . T h i s r e s u l t has been r e p l i c a t e d a c r o s s many s i t u a t i o n s . 42 Rokeach (1971) found t h a t d r a m a t i c a t t i t u d i n a l change c o u l d be a c h i e v e d mere ly by p o i n t i n g out a t t i - tude i n c o n s i s t e n c i e s i n a c o m p e l l i n g f a s h i o n , such t h a t t h e i n d i v i d u a l was f o r c e d f i r s t , t o acknowledge an i n c o n s i s t e n c y between a t t i t u d e s , s econd , t o a t t r i b u t e a d i s c o m f o r t t o t h i s awareness , and t h i r d , t o choose t o endorse one o f the a t t i t u d e s p u b l i c l y , t y p i c a l l y by making a commitment t o c a r r y out some a c t i o n . Bern (1967) o f f e r e d a somewhat d i f f e r e n t but p a r a l l e l i n t e r p r e t a t i o n o f F e s t i n g e r ' s c o g n i t i v e d i s s o n a n c e r e s u l t s w i t h h i s s e l f - p e r c e p t i o n t h e o r y . The c e n t r a l t e n e t o f t h i s t h e o r e t i c a l p o s i t i o n i s t h a t an i n d i v i d u a l i s an o b s e r v e r o f h i s / h e r own b e h a v i o r and l e a r n s about h i s / h e r a t t i t u d e s and a t t r i b u t e s i n much the same way as an e x t e r n a l o b s e r v e r - t h a t i s , h e / s h e o b s e r v e s h i s / h e r e x t e r n a l b e h a v i o r r a t h e r t h a n i n t r a p s y c h i c e v e n t s . Bern sugges t s t h e r e f o r e t h a t the i n d i v i d u a l who has p u b l i c l y s t a t e d an o p i n i o n which i s c o n t r a r y t o a p r e v i o u s l y h e l d but l e s s p u b l i c o p i n i o n and does not have a r a t i o n a l i z i n g j u s t i f i c a t i o n such as s u f f i c i e n t reward , w i l l s u b s e q u e n t l y observe h i s / h e r 43 r e c e n t b e h a v i o r and c onc lu d e t h a t h e / s h e g e n u i n e l y b e l i e v e s the newly s t a t e d p o s i t i o n . I t i s p o s s i b l e t o c o n c l u d e from the work o f F e s t i n g e r , Rokeach, Bern and t h e i r c o l l e a g u e s , t h a t an i n d i v i d u a l tends t o be p r o f o u n d l y a f f e c t e d by p u b l i c examples o f h i s / h e r a t t i t u d e s and b e l i e f s . An e x t r a p o - l a t i o n c o n s i s t e n t w i t h t h e s e a r e a s o f r e s e a r c h i s t h a t an i n d i v i d u a l who r e p o r t s a b e h a v i o r w i t h o u t a l e g i t i - m i z i n g v a r i a b l e such as a s u f f i c i e n t reward w i l l t e n d , t h e r e a f t e r , t o a c c e p t t h i s p o s i t i o n and t o p r e s e n t h i m s e l f / h e r s e l f i n a manner c o n s i s t e n t w i t h t h e s e s t a t e m e n t s . A f u r t h e r e x t r a p o l a t i o n r e l e v a n t t o t h e p r e s e n t s t u d y i s t h a t i n d i v i d u a l s i n a group who e x p r e s s a t t i t u d e s and b e l i e f s i n s u p p o r t o f a group h e l d g o a l , y e t i n c o n s i s t e n t w i t h t h e i r p r e v i o u s p o s i - t i o n , w i l l t h e r e a f t e r be more s t r o n g l y and c o n s i s t e n t l y commit ted t o those s t a t e d p o s i t i o n s as a r e s u l t o f h a v i n g e x p r e s s e d them i n the p u b l i c a r e n a o f t h e g r o u p . In another r e l e v a n t a r e a o f s o c i a l - p s y c h o l o g i c a l r e s e a r c h , i t was found t h a t groups moved c o n s i s t e n t l y toward more unanimous and r i s k y d e c i s i o n s f o l l o w i n g 4 4 group d i s c u s s i o n s . S u b j e c t s i n these s t u d i e s were s e a t e d around a t a b l e and were p r e s e n t e d w i t h t w e l v e dilemmas p r e v i o u s l y d e v e l o p e d by W a l l a c h and Kogan (1964, 1965) . A f t e r p r e s e n t a t i o n o f each dilemma t h e s u b j e c t s were asked t o p u b l i c l y e s t i m a t e t h e r i s k l e v e l a t which they would be w i l l i n g t o make a d e c i s i o n i n agreement w i t h a c o n s i d e r e d course o f a c t i o n . A d i s c u s s i o n ensued and , f o l l o w i n g t h i s , t h e s u b j e c t s were a g a i n asked t o make a r i s k l e v e l e s t i m a t i o n . T h i s second r i s k recommendation showed a s i g n i f i c a n t t e n d e n - cy t o be more r i s k - o r i e n t e d than t h e o r i g i n a l d e c i - s i o n s . F a c t o r s sugges ted t o account f o r t h i s e f f e c t i n c l u d e the f o l l o w i n g : a g e n e r a l i z e d s o c i a l v a l u e on r i s k - t a k i n g (Rabow e t a l . , 1966), f a m i l i a r i z a t i o n w i t h t h e dilemma p r e s e n t e d , d i f f u s i o n o f r e s p o n s i b i l i t y among group members, i n c r e a s e d l e v e l o f i n f o r m a t i o n a r i s i n g from t h e d i s c u s s i o n s ( V i n o k u r , 1971) , i n c r e a s e o f p e r s o n a l i n v o l v e m e n t i n t h e dilemmas by v i r t u e o f the d i s c u s s i o n s , enhancement o f the expec ted v a l u e o f p a y o f f s , o r r e d u c t i o n o f i n d i v i d u a l u n c e r t a i n t y as a f u n c t i o n o f group d i s c u s s i o n (Dion , 1970) . 45 W i l l e m s & C l a r k (1969) found t h a t under the s t a n - d a r d i n s t r u c t i o n s used i n p r e v i o u s r e s e a r c h t h e r e was a h i g h l y s i g n i f i c a n t s h i f t t o r i s k (P<.002) t h a t i s , when open d i s c u s s i o n between group members was p e r m i t t e d . However, where open d i s c u s s i o n was not p e r m i t t e d b u t members exchanged i n f o r m a t i o n on t h e i r r i s k recommenda- t i o n s by means o f h o l d i n g up numbered c a r d s t h e y found a l e s s s i g n i f i c a n t s h i f t (P<.01) . They a l s o found a n o n - s i g n i f i c a n t s h i f t t o r i s k where no d i s c u s s i o n o r i n f o r m a t i o n exchange was p e r m i t t e d but members l i s t e n e d t o an a u d i o t a p e o f a d i s c u s s i o n g r o u p . F i n a l l y t h e r e was a low and n o n - s i g n i f i c a n t s h i f t t o r i s k i n a c o n t r o l group where o n l y a second r i s k - e s t i m a t e was asked f o r . Thus where l e s s group i n t e r a c t i o n was p o s s i b l e , l e s s group s h i f t i n the expec ted d i r e c t i o n was found t o o c c u r . R e s e a r c h i n the a r e a o f the r i s k - s h i f t appears t o i n d i c a t e t h a t t h e a c t i v e v a r i a b l e o f group s i g n i f i c a n t - l y impacts on an i n d i v i d u a l member's judgments . T h i s e f f e c t appears t o v a r y p o s i t i v e l y w i t h degree o f d i s c u s s i o n a l l o w e d (Wi l l ems & C l a r k , 1969) and w i t h 46 group s i z e (from 3 members t o 4 & 5 members) (Teger & P r u i t t , 1967) . The r e p e a t e d e m p i r i c a l f i n d i n g o f a s h i f t t o a r i s k as a f u n c t i o n o f group membership and d e c i s i o n making i s r e l e v a n t t o the c u r r e n t s t u d y . In a c c o r d w i t h t h e r e s e a r c h f i n d i n g s c i t e d above the i n f e r e n c e i s t h a t group membership i n f l u e n c e s b e h a v i o r , i n t h i s case d e c i s i o n - m a k i n g . I t can be e x t r a p o l a t e d t h a t members o f a group who a r e e x p e r i m e n t i n g w i t h c o n t r o l l i n g t h e i r consumpt ion o f a l c o h o l w i l l e x p r e s s more and more r i s k y d r i n k r e d u c t i o n g o a l s ( r i s k y as b e i n g d i f f e r e n t from t h e i r i n i t i a l consumption) as t h e t a s k o f g o a l - s e t t i n g r e p e a t s o v e r t h e l i f e span o f t h e g r o u p . Mode l s Proposed by S o c i a l P s y c h o l o g y t o Unders tand Group I n f l u e n c e S o c i a l p s y c h o l o g i c a l t h e o r i s t s have d e v e l o p e d some h y p o t h e s e s t o account f o r the e v i d e n t i n f l u e n c e o f a group on an i n d i v i d u a l ' s a t t i t u d e s and b e h a v i o r . Z a j o n c ' s (1965) d r i v e t h e o r y ( c i t e d i n Z a j o n c , 1980) i s 47 based l o o s e l y on the mathemat ica l d r i v e p r e d i c t i o n model o f H u l l - S p e n c e . T h i s t h e o r y p r e d i c t s t h a t the " ' m e r e 7 p r e s e n c e " (Zajonc , 1980) o f a n o t h e r w i l l t e n d t o i n c r e a s e a r o u s a l , and t h i s i n t u r n w i l l f a c i l i t a t e per formance o f w e l l - l e a r n e d and s i m p l e (dominant) t a s k s , but w i l l hamper performance o f p o o r l y - l e a r n e d and complex (non-dominant) t a s k s . S e v e r a l adjustments ( d e s c r i b e d by G l a s e r , 1982; G u e r i n & Innes , 1982; P a u l u s , 1983; Lake & A r k i n , 1985; Shaw, 1985) have been proposed t o t h i s mode l . C o t t r e l l (1972, c i t e d i n P a u l u s 1983) adapted t h i s model t o i n c l u d e h i s concept o f a l e a r n e d s o c i a l d r i v e . The l e a r n e d s o c i a l d r i v e was proposed t o be a d r i v e o r i g i n a t i n g i n the s o c i a l h i s t o r y o f the i n d i v i d u a l and r e l a t e d t o the a n t i c i p a t i o n o f p o s i t i v e o r n e g a t i v e e v a l u a t i o n ( p r i m a r i l y n e g a t i v e ) . The d i s t r a c t i o n t h e o r y proposed by Baron (Baron , Moore & Saunders 1978, c i t e d i n P a u l u s , 1983) sugges ted t h a t d r i v e was aroused and the d i f f e r e n t i a l impact was found on dominant v e r s u s non-dominant t a s k s due t o t h e d i s t r a c t i o n e f f e c t s o f an a u d i e n c e . Baron contends 48 t h a t the p r e s e n c e o f o t h e r s i s d i s t r a c t i n g e i t h e r because i t i n c r e a s e s u n c e r t a i n t y r e g a r d i n g a p p r o p r i a t e r e s p o n s e s and l i k e l y outcomes, o r because i t i n c r e a s e s e v a l u a t i o n a p p r e h e n s i o n , o r because i t i n d u c e s a t endency toward s o c i a l compar i son and s e l f - e v a l u a t i o n from an e x t e r n a l p e r s p e c t i v e . T h i s l a t t e r f a c t o r i s r e m i n i s c e n t o f Bern's s e l f - a p p r a i s a l h y p o t h e s i s . Duva l and W i c k l u n d (1972, c i t e d i n P a u l u s , 1983) sugges ted t h a t t h e presence o f o t h e r s f u n c t i o n s as an impetus t o r e f l e c t on o n e ' s performance as i f o u t s i d e o n e s e l f and t o become aware o f the d i s c r e p a n c i e s between t h e per formance o f t h e r e a l s e l f and t h e per formance g o a l s o f the s u b j e c t ' s i d e a l s e l f . T h i s awareness i n c r e a s e s m o t i v a t i o n t o more c l o s e l y a p p r o x i - mate the i d e a l s e l f . C a r v e r & S c h e i r (1981, c i t e d i n P a u l u s , 1983) p r o p o s e d a c y b e r n e t i c model u t i l i z i n g a f eedback l o o p o f t h e T e s t - O p e r a t e - T e s t - E x i t o r TOTE v a r i e t y . In t h e p r e s e n c e o f o t h e r s they propose t h a t an i n d i v i d u a l s cans f o r d i s c r e p a n c i e s more f r e q u e n t l y and t h u s has more immediate v o l i t i o n a l c o n t r o l o f h i s b e h a v i o r . 49 T u r n e r (1985) ( T u r n e r & Oakes , 1986) p r o p o s e d a model which emphasizes t h e s o c i a l i d e n t i t y o f t h e i n d i v i d u a l . T u r n e r proposes t h a t s o c i a l i d e n t i t y i s a s e l f - c o n c e p t which i n c l u d e s b e i n g p a r t o f a s o c i a l g r o u p , as u n d e r s t a n d i n g o n e s e l f as more s i m i l a r t o members o f t h a t s o c i a l group than t o o t h e r s , and as u n d e r s t a n d i n g o t h e r members o f the group as b e i n g s i m i l a r t o the i d e a l s e l f . S o c i a l i n f l u e n c e , i n t h i s m o d e l , i s a f u n c t i o n o f t h e need t o e x p e r i e n c e c o n s e n - sus w i t h p e r s o n s p e r c e i v e d as s i m i l a r t o o n e s e l f . A n o t h e r model o f groups proposed was L a t a n e ' s (1981, c i t e d i n T a n f o r d & Penrod , 1984) s o c i a l impact m o d e l . A c c o r d i n g t o t h i s model , the impact o f a m a j o r i t y o r m i n o r i t y i n f l u e n c e i s a f u n c t i o n o f t h e s t r e n g t h ( t h a t i s , t h e s t a t u s o r r e s o u r c e s o f t h e i n f l u e n c e s o u r c e ) , the immediacy ( t h a t i s , t h e p r o x i m i - t y o f t h e i n f l u e n c e s o u r c e t o the t a r g e t ) , and t h e r a t i o o f the i n f l u e n c e r s t o the number o f p e o p l e i n f l u - enced . The above t h e o r i e s , w h i l e they a l l have b o t h s u p p o r t and problems i n the e m p i r i c a l l i t e r a t u r e , 50 i n d i c a t e t h a t , a t the v e r y l e a s t , some a s p e c t s o f ' g r o u p n e s s ' has c o n s i s t e n t l y been p r o p o s e d t o be l i n k e d t o s y s t e m a t i c s h i f t s i n b e h a v i o r . Z im bardo , Ebbesen , and M a s l a c h (1977) summarize t h e impact o f group membership on a t t i t u d e and b e h a v i o r change u t i l i z i n g many o f t h e r e s u l t s o f Z i m b a r d o ' s p r e v i o u s r e s e a r c h . R e l e v a n t among t h e s e a r e : 1) a t t i t u d e s a r e i n f l u e n c e d by group norms and g o a l s o f t h e group t o which one b e l o n g s ; 2) c o n f o r m i n g t o these group norms i n r e w a r d e d , not c o n f o r m i n g i s p u n i s h e d by the g r o u p ; 3) group i n f l u e n c e i s more e f f e c t i v e when the group meets s o c i a l and e m o t i o n a l needs; 4) groups may i n f l u e n c e by d i f f u s i o n o f r e s p o n s i b i l i - t y , i m i t a t i o n , anonymity , and b e h a v i o r a l c o n t a - g i o n . ( I m i t a t i o n i s t h e e f f e c t o f m o d e l i n g and whole o r p a r t r e p e t i t i o n o f t h i s b e h a v i o r by a n o t h e r , which appears t o i n c r e a s e t h e l i k e l i h o o d o f f u t u r e r e p e t i t i o n s o f the b e h a v i o r by t h e o t h e r . B e h a v i o r a l c o n t a g i o n r e f e r s t o b e i n g i n f l u e n c e d t o p a r t a k e i n s i m i l a r b e h a v i o r , 51 a t t i t u d e s , and emotions as o t h e r s based on the p r o x i m i t y and p e r c e i v e d e m o t i o n a l c l o s e n e s s t o t h e o t h e r s ) ; 5) a t t i t u d e s t h a t a r e p u b l i c l y e x p r e s s e d a r e more r e s i s t a n t t o change than those no t so e x p r e s s e d ; 6) d i s c u s s i o n p a r t i c i p a t i o n i n c r e a s e s v u l n e r a b i l i t y t o a t t i t u d e change . In r e l a t i o n t o the c u r r e n t s t u d y i t can be e x t r a p - o l a t e d t h a t group members may p u b l i c i t y expres s group norms and g o a l s c o n s i s t e n t w i t h the program g o a l under d i s c u s s i o n . Group members may be seen as m u t u a l l y s u p p o r t i v e p e e r s who model t h e i r b e h a v i o r on each o t h e r and who demonstra te an i n c r e a s i n g mutua l commitment t o t h e s t a t e d g o a l s . These f a c t o r s may be proposed t o f a c i l i t a t e change i n a t t i t u d e and b e h a v i o r i n t h e d i r e c t i o n o f s u c c e s s f u l accompl ishment o f a l c o h o l r e d u c t i o n . A p p l i e d S o c i a l P s y c h o l o g y and Group I n f l u e n c e A p p l i e d s o c i a l p s y c h o l o g y has a l s o made some r e l e v a n t c o n t r i b u t i o n s to the c u r r e n t s t u d y . S e v e r a l 52 r e s e a r c h e r s have t e s t e d the impact o f group membership on b e h a v i o r such as subs tance abuse and i t s c o n t r o l . A s e l e c t i o n o f t h e s e s t u d i e s i s rev iewed be low. C o l l i n s , P a r k s , & M a r l a t t (1985) s t u d i e d s e v e r a l a s p e c t s o f s o c i a l i n f l u e n c e models . The most i m p o r t a n t o f t h e i r f i n d i n g s was t h a t mode l ing o c c u r r e d more c o n s i s t e n t l y where the c o n f e d e r a t e made e f f o r t s t o be s o c i a b l e . Thus i m i t a t i o n o f the d r i n k i n g consumption and p a c i n g o f another appeared most l i k e l y when the o t h e r was p r e s e n t e d as a f f a b l e and f r i e n d l y . R e l a t e d t o t h i s f i n d i n g , B i x e n s t i n e & A b a s c a l (1985) c a r r i e d out a group a s s e r t i v e n e s s i n t e r v e n t i o n w i t h t h r e e - p e r s o n g r o u p s , each c o n t a i n i n g one c o n f e d e r - a t e who modeled s u c c e s s / f a i l u r e and w a r m t h / c o l d n e s s i n a 2X2 d e s i g n . The a u t h o r s found t h a t b o t h succes s m o d e l i n g and warmth m o d e l i n g were r e l a t e d t o r e p o r t e d g a i n s i n a s s e r t i v e n e s s and t h a t the c o n f e d e r a t e was p e r c e i v e d as warm i n b o t h c a s e s . Thus s u c c e s s i n o t h e r s i s a t t r a c t i v e and may s t i m u l a t e e m u l a t i o n . 53 E t r i n g e r e t a l . (1984) m a n i p u l a t e d s o c i a l c o h e s i o n i n a smoking c e s s a t i o n treatment and found a s i g n i f i - c a n t l y h i g h e r succes s r a t e a s s o c i a t e d w i t h the h i g h e r c o h e s i o n c o n d i t i o n . Whi l e t h i s o f f e r s t e n t a t i v e s u p p o r t t o the e f f e c t o f group c o h e s i o n on t r e a t m e n t i m p a c t , t h i s s t u d y s u f f e r e d from p r e - t e s t d i f f e r e n c e s i n one o f the c o n d i t i o n s which i n f l a t e d the a p p a r e n t e f f e c t o f t h i s v a r i a b l e . C l a r k e e t a l . (1985) s t u d i e d changes i n a l c o h o l use p a t t e r n s d u r i n g the f i r s t y e a r o f m e d i c a l s c h o o l . They found t h a t w h i l e a l c o h o l use dropped somewhat among males and remained the same among f emales , t h e b e l i e f s o f a l l t h e s t u d e n t s about a p p r o p r i a t e consump- t i o n converged c o n s i d e r a b l y over the c o u r s e o f t h e y e a r . The a u t h o r s propose t h a t an i n i t i a l c o l l e c t i o n o f s t u d e n t s each w i t h h i s o r her own d i v e r s e r e f e r e n c e g r o u p s c o a l e s c e d i n t o a power fu l group w i t h i n f l u e n c e on i t s members. E i s e r & Van Der P l i g t (1984) s u r v e y e d a d o l e s c e n t smokers i n an e f f o r t t o e x p l o r e the o r i g i n s o f smoking h a b i t s . As an outcome o f t h e i r s t u d y the a u t h o r s 54 r e j e c t e d the h y p o t h e s i s o f p e e r p r e s s u r e and p r o p o s e d a h y p o t h e s i s based on group f o r m a t i o n . They sugges ted t h a t a c h o i c e t o j o i n a group i s b a s e d , i n p a r t , on p e r c e i v e d s i m i l a r i t i e s between the i n d i v i d u a l and t h e g r o u p . T h i s w i l l be f o l l o w e d by a growing consensus o f b e l i e f s w i t h i n the group and p e r c e i v e d d i s s i m i l a r i t y t o o t h e r g r o u p s . One group v a l u e may be t o smoke a n d , i n f a c t , the a u t h o r s note t h a t the l e a d e r s o f smoking groups are l i k e l y t o be smokers . However smoking b e h a v i o r i n group members, they c o n t e n d , i s not t h e e f f e c t o f mode l ing by t h e l e a d e r s b u t r a t h e r o f s h a r e d v a l u e s i n the group as a whole . In an expans ion o f t h i s s t u d y E i s e r (1985) d e v e l - ops a s o c i a l i n f l u e n c e mode l . He sugges t s t h a t s o c i a l i d e n t i t y f a c t o r s w i t h r e f e r e n c e t o the p r i m a r y s o c i a l group a r e as f o l l o w s : the s o c i a l group c o n t a i n s t h e s t a n d a r d s f o r s e l f - e v a l u a t i o n , i t c o n t a i n s the major s o u r c e s o f i n f o r m a t i o n r e g a r d i n g c h o i c e s o f a c t i v i t i e s and c o n s i d e r e d b e h a v i o r , and i t i s the major s o u r c e o f e x p e c t a n c i e s r e g a r d i n g b e h a v i o r such as smoking . 55 Solomon and H a r f o r d (1984) s u r v e y e d a p o p u l a t i o n i n o r d e r t o compare d r i n k i n g norms w i t h a c t u a l d r i n k i n g b e h a v i o r . They found t h a t t h e norms and d r i n k i n g b e h a v i o r tended t o be de termined by the c o n t e x t r a t h e r t h a n by some p r e - s e t p a t t e r n s o f consumpt ion . Thus s o c i a l i n f l u e n c e i s more i m p o r t a n t t h a n p a s t b e h a v i o r . I t appears from the above a p p l i e d s o c i a l p s y c h o - l o g i c a l l i t e r a t u r e t h a t the f i n d i n g s o f the l a b o r a t o r y i n s o c i a l p s y c h o l o g y a r e r e p l i c a t e d i n the f i e l d . S o c i a l i n f l u e n c e i s c l e a r l y a key v a r i a b l e i n t h e d e t e r m i n a t i o n o f b e h a v i o r . I t has been found t h a t groups i n f l u e n c e members t o change i n v a r i o u s and d r a m a t i c ways. As a consequence , i f a l l o t h e r f a c t o r s were h e l d c o n s t a n t - a group p r e s e n t a t i o n , c o n t a i n i n g as i t does t h e s e s o c i a l i n f l u e n c e s , would be expec ted t o have a d e c i d e d l y s t r o n g e r impact t h a n i n d i v i d u a l t r e a t m e n t . 56 Group V e r s u s I n d i v i d u a l Formats In G e n e r a l C o u n s e l i n g Trea tment In t h i s s e c t i o n the g e n e r a l outcomes o f p r e v i o u s c l i n i c a l and c o u n s e l i n g r e s e a r c h c o n t r a s t i n g group and i n d i v i d u a l t r e a t m e n t formats a r e p r e s e n t e d a l o n g w i t h t h e major m e t h o d o l o g i c a l problems e n c o u n t e r e d . I t appears from a g e n e r a l r e v i e w o f the c l i n i c a l and c o u n s e l i n g l i t e r a t u r e t h a t , c o n t r a r y t o t h e e x p e c - t a t i o n drawn from t h e l i t e r a t u r e i n s o c i a l p s y c h o l o g y , t h e r e has emerged no o u t s t a n d i n g advantage t o group o v e r i n d i v i d u a l f o r m a t . In f a c t , i n two major r e v i e w s by O r l i n s k y & Howard (1978) and L u b o r s k y e t a l . (1975) , s i x t y - e i g h t p e r c e n t o f the t o t a l o f 31 s t u d i e s c i t e d found no s i g n i f i c a n t d i f f e r e n c e i n outcome between t h e two f o r m a t s . Of the r e m a i n i n g t h i r t y - t w o p e r c e n t o f s t u d i e s which found a s i g n i f i c a n t d i f f e r - e n c e , r e s u l t s were s p l i t about e q u a l l y between t h o s e f a v o r i n g group and i n d i v i d u a l f o r m a t . O t h e r s t u d i e s r e v i e w e d s e p a r a t e l y (Aughenbaugh, 1968; S c i s s o n s & N j a a , 1973; R o c k w e l l , 1976; K i n g s l e y & W i l s o n , 1977; 57 B r o w n e l l , 1978; and L i n e h a n , 1979) r e v e a l e d the same r e s u l t s : f o u r o f the s i x f i n d i n g no s i g n i f i c a n t d i f f e r e n c e and one each f a v o r i n g group and i n d i v i d u a l . However, s e v e r e and p e r s i s t e n t m e t h o d o l o g i c a l prob lems have o c c u r r e d i n s t u d i e s i n t h i s a r e a . An example o f some o f these problems can be p r e s e n t e d i n t h e R o c k w e l l s t u d y (1976), the one o f s i x s e p a r a t e l y r e v i e w e d s t u d i e s which suggests t h a t an i n d i v i d u a l format has g r e a t e r t rea tment impac t . F i r s t , i n Rock- w e l l ' s s t u d y c l i e n t s were not randomly a s s i g n e d t o t r e a t m e n t . Second , the t rea tment m o d a l i t y was not d e s c r i b e d o t h e r t h a n as " . . . b e s t c h a r a c t e r i z e d as e c l e c t i c .psychotherapy" (p. 188) , i n d i c a t i n g the l a c k o f a c o h e r e n t o r c o n s i s t e n t t r ea tment mode l . T h i r d , t h e sample i s q u i t e un ique i n c o n s i s t i n g l a r g e l y o f c l i e n t s who were s u f f e r i n g from r e a c t i v e d i s t r e s s which may w e l l have been s e l f - l i m i t i n g i n any c a s e . As n o t e d above , the r e s u l t s o f s t u d i e s c o n t r a s t i n g group and i n d i v i d u a l t r ea tment s a r e r e n d e r e d s u s p e c t by p e r s i s t e n t m e t h o d o l o g i c a l problems e n c o u n t e r e d , which l e a v e t h e r e s u l t s o f the s t u d i e s s u r v e y e d l e s s t h a n 58 c o n c l u s i v e and , most o f t e n , c o n f u s i n g . B l o c h e t a l . (1981) , K l e i n (1983), O r l i n s k y & Howard (1978) and P a t t i s o n (1979), blame d e s i g n p r o b l e m s , inadequate measures , f a d r e s e a r c h , and t h e i n c o n s i s t e n c y o f d e f i n i t i o n s a c r o s s r e s e a r c h as major prob lems . F u r - t h e r , i t may be argued t h a t i n c o n s i s t e n c i e s a c r o s s formats l e a d i n g t o the c o n f o u n d i n g o f t rea tment format and t r e a t m e n t c o n t e n t i s endemic t o the r e s e a r c h a r e a . Bednar and K a u l (1978) c i t e s e v e r a l s evere examples o f t h i s prob lem i n which c o n t r a s t s might be , f o r i n s t a n c e , between a t r a n s a c t i o n a l - a n a l y s i s c o n t e n t i n a group t r e a t m e n t f o r m a t , and b e h a v i o r m o d i f i c a t i o n c o n t e n t i n an i n d i v i d u a l f o r m a t . A n o t a b l e e x c e p t i o n c o n s i d e r e d above , t h e M i l l e r and T a y l o r (1980) s t u d y , i s s e r i o u s l y f l a w e d i n o t h e r r e s p e c t s . As a r e s u l t o f these k i n d s o f problems o f method- o l o g y , no d e f i n i t i v e c o n c l u s i o n s about the c o m p a r a t i v e impac t s o f group and i n d i v i d u a l t r e a t m e n t s may be d e r i v e d from t h e l i t e r a t u r e t o d a t e . However, a t the t h e o r e t i c a l l e v e l t h e r e i s r e a s o n t o propose t h a t a group format may be more e f f e c t i v e o v e r a l l i n b r i n g i n g about change such as lowered consumpt ion i n prob lem 59 d r i n k e r s . F o l l o w i n g i s a d i s c u s s i o n o f the t h e r a p e u t i c f a c t o r s t h a t have been proposed t o account f o r the impact o f group and i n d i v i d u a l t r e a t m e n t s r e s p e c t i v e l y . T h e r a p e u t i c F a c t o r s and Group Treatment K o v e l (1976) i n h i s p o p u l a r r e v i e w o f t h e r a p i e s o f f e r e d t h e f o l l o w i n g c o n t r a s t o f group and i n d i v i d u a l t r e a t m e n t s : "Group t h e r a p y . . . o f f e r s b o t h a r e a d i e r a c c e s s t o i n t e r p e r s o n a l n e u r o t i c p a t t e r n s and a d i f f e r e n t vantage on those p a t t e r n s : we g e t t o see o u r - s e l v e s as o t h e r s see u s . The group i s more d r a m a t i c , more f i l l e d w i t h i n t e n s e f e e l i n g , a c t i o n and r i s k t a k i n g , thus i t i s l i k e l y t o produce b e h a v i o r change more r a p i d l y . " (p.180) O h l s e n (1977) proposes t h a t groups a r e more advantageous t h a n i n d i v i d u a l c o u n s e l i n g i n t h a t t h e y f o c u s a t t e n t i o n on the p r e s e n t group c o n t e x t r a t h e r t h a n on p r i o r h i s t o r y o r e x t e r n a l s i t u a t i o n s , t h u s p r o v i d i n g more o p p o r t u n i t y f o r f eedback on members' p a t t e r n s o f i n t e r a c t i o n s . Dinkmeyer and Munro (1971) sugges t t h a t t h i s feedback can l e a d t o t r y i n g out new forms o f b e h a v i o r i n the g r o u p . O t h e r reasons p o i n t e d out by t h e s e a u t h o r s f o r p r e f e r r i n g a group c o n t e x t a r e t h a t members l e a r n by o b s e r v i n g o t h e r s and a r e 60 encouraged t h a t o t h e r s have s i m i l a r p r o b l e m s , t h a t groups p r o v i d e an o p p o r t u n i t y f o r l e a r n i n g e f f e c t i v e v a l u e s , and t h a t groups p r o v i d e an o p p o r t u n i t y t o meet a b a s i c need f o r b e l o n g i n g by g i v i n g and r e c e i v i n g a f f e c t i o n w i t h o t h e r group members. As no ted i n the p r e v i o u s s e c t i o n , s o c i a l p s y c h o l o - gy r e s e a r c h sugges t s t h a t some a d d i t i o n a l and u n i q u e impact o f groups may be expec ted t h a t would enhance t r e a t m e n t impact beyond t h a t a v a i l a b l e i n i n d i v i d u a l t r e a t m e n t . The 'mere p r e s e n c e ' o f o t h e r s appears t o have a l a r g e i n f l u e n c e on p e r c e p t i o n and b e h a v i o r . T h i s would be expected t o be an a c t i v e component i n group t r e a t m e n t . In a d d i t i o n t o the s o c i a l p s y c h o l o g y r e s e a r c h , some i m p o r t a n t t h e r a p e u t i c a s p e c t s o f group i n t e r v e n t i o n have been d e s c r i b e d i n t h e c l i n i c a l and c o u n s e l i n g l i t e r a t u r e on g r o u p s . F o r Schutz ( i n Dimock, 1970) t h e major t h e r a p e u t i c i n f l u e n c e i s t o be found i n the deve lopment o f t h e group i t s e l f . The group p r o g r e s s e s t h r o u g h t h e f o l l o w - i n g s u c c e s s i v e s tages : i n i t i a l l y members seek t o become p a r t o f the group and t o d e f i n e t h e i r p o s i t i o n 61 i n i t . Next ensues a s t r u g g l e f o r c o n t r o l . Then a s t a g e o f s h a r i n g o f r e s p o n s i b i l i t y and c o h e s i o n f o l - l o w s . F i n a l l y , i n t i m a c y and i n d i v i d u a l i t y emerge, l e a d i n g t o a deeper and more open s h a r i n g and p r o d u c - t i v e p r o b l e m - s o l v i n g . Schutz u n d e r s t o o d t h e s e s t a g e s as b e i n g h i g h l y i n v o l v i n g t o a l l group members and as b e i n g p o w e r f u l i n g r e d i e n t s i n t r e a t m e n t . H i s work c l e a r l y sugges t s t h a t , where a group i s t h e t r e a t m e n t f o r m a t , t h e s e s t a g e s w i l l i n e v i t a b l y o c c u r i n a power- f u l and e n g r o s s i n g way. S i m i l a r t o S c h u t z , Gibb (1964) p r o p o s e s f o u r b a s i c s t a g e s i n group development i d e n t i f i e d as a c c e p t a n c e o r t r u s t f o r m a t i o n , d a t a f low o r the open e x p r e s s i o n o f t h o u g h t s and f e e l i n g s , g o a l f o r m a t i o n , and s o c i a l c o n t r o l . Perhaps t h e most b a s i c o f t h e s e i s t h e s t a g e o f t r u s t f o r m a t i o n i n which t h e i n d i v i d u a l group members l e a r n t o a c c e p t themse lves and o t h e r s , t o e s t a b l i s h membership i n the g r o u p , and t o i n c r e a s e s e l f - c o n f i d e n c e . By d e v e l o p i n g h i g h l e v e l s o f t r u s t , members reduce a n x i e t y , thus becoming more a b l e t o p r o c e s s i n f o r m a t i o n and engage i n i n t e r a c t i o n s w h i c h f a c i l i t a t e i n s i g h t . G i b b ' s work s u g g e s t s t h a t where a 62 group e x i s t s and i s a b l e t o work t h r o u g h t h e s e s t a g e s , p a r t i c u l a r l y t r u s t f o r m a t i o n , change w i l l o c c u r . Baeke land (1977) i n d i c a t e s t h a t a group format adds t o t h e r a p e u t i c i n t e r v e n t i o n s i n the f o l l o w i n g ways: i t p r o v i d e s a f a m i l y warmth and c o h e s i o n , i t h e l p s members p r e p a r e f o r t h e f u t u r e by e x p e r i m e n t i n g w i t h r e l a t i n g , and i t e n a b l e s members t o e x p e r i e n c e g i v i n g as w e l l as r e c e i v i n g i n t h e i r i n t e r a c t i o n s . Yalom (1975) sugges t s t h a t the f o l l o w i n g t h e r a p e u - t i c f a c t o r s c r e a t e t r e a t m e n t impact i n g r o u p s : a l t r u - i sm o r h e l p i n g o t h e r s , group c o h e s i v e n e s s o r b e i n g p a r t o f a g r o u p , u n i v e r s a l i t y o r r e a l i z i n g t h a t o t h e r s a l s o s h a r e o n e ' s p r o b l e m s , i n t e r p e r s o n a l l e a r n i n g ( input ) o r l e a r n i n g how one i s e x p e r i e n c e d by o t h e r s , i n t e r p e r s o n - a l l e a r n i n g (output) o r c h a n g i n g the way one r e l a t e s t o o t h e r s , g u i d a n c e o r a c c e p t i n g a d v i c e , c a t h a r s i s o r p o w e r f u l e m o t i o n a l e x p r e s s i o n , i d e n t i f i c a t i o n o r l e a r n i n g t o be l i k e o t h e r s one a d m i r e s , f a m i l y r e e n a c t - ment o r r e c a p i t u l a t i n g problems i n t h e f a m i l y o f o r i g i n w i t h i n t h e group s e t t i n g , s e l f - u n d e r s t a n d i n g , i n s t i l l a t i o n o f hope, and an e x i s t e n t i a l f a c t o r i n 63 w h i c h one l e a r n s t h a t one i s e s s e n t i a l l y a l o n e and r e s p o n s i b l e f o r o n e s e l f . Group p s y c h o t h e r a p y a c c o r d i n g t o H i l l (1975) o f f e r s t h e f o l l o w i n g unique t r e a t m e n t o p p o r t u n i t i e s : v e n t i l a t i o n o f a f f e c t , acceptance by o t h e r group members, l e a r n i n g by watch ing o t h e r s who a r e a d d r e s s i n g s i m i l a r problems t o one ' s own, and the a b i l i t y t o a b s t r a c t and r e f l e c t on one ' s i s s u e s . S i m i l a r l y , Le iberman (1980) proposes f i v e f a c t o r s i n h e r e n t i n the group p r o c e s s . In a g r o u p , c o h e s i v e - nes s d e v e l o p s among members and i s e x p e r i e n c e d as a c c e p t a n c e and s u p p o r t . P r e s s u r e i s e x e r t e d by the group f o r members' b e h a v i o r s t o conform t o m u t u a l l y a c c e p t e d norms. The group s e r v e s as an a l t e r n a t i v e s o c i a l env i ronment , r e d e f i n i n g v a l u e s f o r i t s members. The group a l l o w s b o t h the e x p r e s s i o n and c o n t r o l o f a f f e c t as a p p r o p r i a t e . F i n a l l y , the group p r o v i d e s a c o n t e x t f o r t h e s o c i a l comparison o f o n e s e l f t o o t h e r s . B l o c h e t a l . (1981) o f f e r e l e v e n major t h e r a p e u t i c f a c t o r s a v a i l a b l e i n g r o u p s . These f a c t o r s a r e d e r i v e d 64 from C o r s i n i & Rosenberg (1955) as a r e Y a l o m ' s . They i n c l u d e : s e l f - d i s c l o s u r e , i n t e r a c t i o n , acceptance o r c o h e s i v e n e s s , i n s i g h t ( e s p e c i a l l y i n t o r e l a t i o n s h i p s w i t h o t h e r s ) , c a t h a r s i s , g u i d a n c e , u n i v e r s a l i t y , a l t r u i s m , v i c a r i o u s l e a r n i n g , the i n s t i l l a t i o n o f hope, and an e x i s t e n t i a l f a c t o r . Long & Cope (1980) a s s e s s c u r a t i v e f a c t o r s u t i l i z - i n g Y a l o m ' s (1975) 12 f a c t o r Q - S o r t t e c h n i q u e on an i n c a r c e r a t e d o f f e n d e r p o p u l a t i o n t r e a t e d w i t h group t h e r a p y f o r an average o f seven months and a minimum o f one month. The r e s u l t i n g rank o r d e r i n g o f Y a l o m ' s f a c t o r s appears as : (1) c a t h a r s i s , (2) c o h e s i v e n e s s , (3) i n t e r p e r s o n a l l e a r n i n g ( i n p u t ) , (4) i n t e r p e r s o n a l l e a r n i n g ( o u t p u t ) , (5) s e l f - u n d e r s t a n d i n g , (6) e x i s t e n - t i a l f a c t o r , (7) a l t r u i s m , (8) i n s t i l l a t i o n o f hope , (9) g u i d a n c e , (10) f a m i l y reenactment , (11) u n i v e r s a l i - t y , (12) i d e n t i f i c a t i o n . T h i s r a n k i n g i s s i g n i f i c a n t l y c o r r e l a t e d t o t h a t r e p o r t e d by Yalom i n 1975. B u t l e r & Fuhriman (1983) rev i ew r e s e a r c h s t u d i e s o f t h e r a p e u t i c f a c t o r s i n groups as t h e s e were r a t e d by p a r t i c i p a n t s . Most s t u d i e s used the Yalom (1975) 65 q u e s t i o n n a i r e and the Yalom twe lve f a c t o r mode l . C l i e n t s were i n v o l v e d i n i n p a t i e n t , o u t p a t i e n t and p e r s o n a l growth g r o u p s . The most s a l i e n t f a c t o r s among t h e seven s t u d i e s rev iewed by the a u t h o r s p r o v e d t o be s e l f - u n d e r s t a n d i n g , c a t h a r s i s , and i n t e r p e r s o n a l l e a r n i n g ( i n p u t ) . There i s , however, some d i f f e r e n c e between groups i n r a n k i n g o f these f a c t o r s - i n p a t i e n t g r o u p s r a n k i n g c o h e s i v e n e s s f i r s t w h i l e o u t p a t i e n t and p e r s o n a l growth groups gave p r i o r i t y t o s e l f - u n d e r - s t a n d i n g , c a t h a r s i s , and i n t e r p e r s o n a l l e a r n i n g . B u t l e r & Fuhriman r e p o r t s e v e r a l c r i t i c i s m s t h a t have been d i r e c t e d a t the Yalom model o f t h e r a p e u t i c f a c t o r s . , F i r s t i s the p r i m a r y f o c u s on the " h e r e - a n d - now" i n t rea tment and the subsequent under -emphas i s o f i n s i g h t i n t o the c o n t r i b u t i o n o f e a r l i e r l i f e e v e n t s on c u r r e n t i n t e r a c t i o n s t y l e s . Thus a d d i t i o n a l t h e r a p e u - t i c f a c t o r s may be m i s s i n g which a r e p r i m a r i l y r e l a t e d t o p e r s o n a l h i s t o r y . Second, the a u t h o r s r e p o r t t h a t an i t e m a n a l y s i s was completed o f t h e f a c t o r s , i n d i c a t - i n g a h i g h c o r r e l a t i o n among them. T h i s may r e v e a l , t h e y s u g g e s t , t h a t , i n r e a l i t y , fewer o r more u n i t a r y f a c t o r s may e x i s t t h a n the t w e l v e l i s t e d . F u r t h e r , 66 B u t l e r & Fuhriman a l s o note t h a t t h e f a c t o r s a r e a s s e s s e d by s e l f - r e p o r t , u s i n g Y a l o m ' s measure , and i m p l y the c r i t i c i s m t h a t the t h e o r e t i c a l l y d e r i v e d model (Yalom, 1975) used i n d e s i g n i n g t h i s measure l i m i t e d d a t a t o t h o s e which s u p p o r t e d t h e mode l . These d a t a thus may p r o v i d e l e s s t h a n the t o t a l p i c t u r e o f c u r a t i v e f a c t o r s . R e l a t e d t o t h i s , B l o c h (1981) no te s t h a t these t h e r a p e u t i c f a c t o r s a r e o n l y i n c o n s i s t e n t l y found t o be r e l a t e d t o t r e a t m e n t outcome. K l e i n (1983) c r i t i c i z e s t h a t t h e v a l i d i t y o f c o n s t r u c t s p r o p o s e d t o be i m p a c t f u l i n group t rea tment i n g e n e r a l remains s u s p e c t due t o p e r s i s t e n t m e t h o d o l o g i c a l prob lems i n r e s e a r c h . These c r i t i c i s m s sugges t t h a t more e x p l o r - a t o r y s tudy may be r e q u i r e d t o a d e q u a t e l y d e f i n e t h e r a p e u t i c f a c t o r s . In de fense o f an i n d i v i d u a l t r e a t m e n t a p p r o a c h i t may be argued t h a t some o r a l l o f t h e s e c u r a t i v e f a c t o r s would be a v a i l a b l e i n an i n d i v i d u a l f o r m a t . N a t a l i and C v i t k o v i c (1977) m a i n t a i n t h a t group t h e r a p y " . . . a d d s a s i g n i f i c a n t t h e r a p e u t i c d i m e n s i o n t o t h e t r e a t m e n t p r o c e s s " (P.50) and p r o c e e d t o d e s c r i b e t h i s d i m e n s i o n as " . . . h e l p i n g (group members) t o r e s o l v e 67 i n t e r p e r s o n a l c o n f l i c t s , t o d e v e l o p e f f e c t i v e i n t e r p e r - s o n a l s k i l l s , and t o d e v e l o p h i g h e r l e v e l s o f s e l f - a n d - o t h e r awareness ." (P.51) C l e a r l y , however, t h e s e f e a t u r e s are not e x c l u s i v e t o groups s i n c e some l e a r n - i n g o f s e l f - a w a r e n e s s i s u s u a l l y i n v o l v e d i n i n d i v i d u a l t r e a t m e n t as w e l l . I f B l o c h ' s o r Ya lom's c a t e g o r i e s a r e c o n s i d e r e d ( they may be used i n t e r c h a n g e a b l y s i n c e t h e y a r e so h i g h l y c o n s i s t e n t w i t h each o t h e r ) , t h e f a c t o r s o f s e l f - d i s c l o s u r e , a c c e p t a n c e , i n s i g h t , c a t h a r s i s , g u i d a n c e , the i n s t i l l a t i o n o f hope , and t h e e x i s t e n t i a l f a c t o r a r e t h e o r e t i c a l l y a t l e a s t a v a i l a b l e i n an i n d i v i d u a l t h e r a p y c o n t e x t . T h i s l e a v e s i n t e r a c - t i o n , c o h e s i v e n e s s , u n i v e r s a l i t y , a l t r u i s m , and v i c a r i - ous l e a r n i n g as p o s s i b l e u n i q u e group f a c t o r s . Indeed , t h e s e f e a t u r e s a r e , i t would seem, the main a s p e c t s by w h i c h group and i n d i v i d u a l approaches a r e p r o p o s e d t o d i f f e r . Thus , i f the c u r r e n t r e p r e s e n t a t i o n o f t h e r a - p e u t i c f a c t o r s i s t a k e n t o be a c c u r a t e , t h e p r e s e n t s t u d y can be seen as t e s t i n g whether o r no t i n t e r a c - t i o n , c o h e s i v e n e s s , u n i v e r s a l i t y , a l t r u i s m , and v i c a r i o u s l e a r n i n g add s i g n i f i c a n t l y t o t r e a t m e n t power and t h e r e f o r e c o n s t i t u t e a un ique advantage o f group o v e r i n d i v i d u a l t r e a t m e n t . 68 I t i s i m p o r t a n t t o note t h a t the above t h e r a p e u t i c components a r e no t the most d r a m a t i c o r a f f e c t i v e l y p o w e r f u l among B l o c h ' s o r Y a l o m ' s l i s t s a n d , i n f a c t , a f f e c t i v e i n t e n s i t y i s n o t , by i m p l i c a t i o n , an i m p o r - t a n t d i s t i n g u i s h i n g f e a t u r e o f g r o u p s . Hence a compar- i s o n o f group v e r s u s i n d i v i d u a l t r e a t m e n t s need not c o n t r a s t p o w e r f u l a f f e c t i v e t h e r a p i e s b u t s i m p l y t h e r a p e u t i c methods known t o be e f f e c t i v e t h a t d i f f e r on t h e s e components . In s e a r c h i n g f o r un ique and added f e a t u r e s o f group approaches i t i s a l s o u s e f u l t o go beyond the e x p e r i m e n t a l l a b o r a t o r y r e s e a r c h o f the s o c i a l p s y c h o l - o g i s t s and t h e t h e o r y o f the c l i n i c a l group r e s e a r c h e r s i n t o t h e p r a c t i c a l a s p e c t s o f t h e a v a i l a b l e s e l f - h e l p g r o u p s . W h i l e numerous c r i t i c i s m s have been o f f e r e d o f A l c o h o l i c s Anonymous, ( P a t t i s o n e t a l . , 1977) i t i s c l e a r t h a t t h e movement does have some p o w e r f u l t r e a t - ment components f o r many p e o p l e . These components s h o u l d be s i m i l a r t o the t h e r a p e u t i c f a c t o r s o u t l i n e d by B l o c h and o t h e r s above. 69 K i s s i n (1977) i n d i s c u s s i n g the t h e r a p e u t i c f a c t o r s o f A . A . sugges ts t h a t i t has many o f t h e components common t o e x i s t e n t i a l p s y c h o l o g y , such as c o n f r o n t a t i o n , a p r e s s u r e to a c c e p t r e a l i t y , and an emphasis on openness and h o n e s t y . These c l e a r l y p a r a l l e l B l o c h ' s and Yalom's f a c t o r s . I n a d d i t i o n , A . A . p r o v i d e s models o f changed b e h a v i o r , as w e l l as s u s t e n a n c e and mora l s u p p o r t t o i t s members. F i n a l l y , i t p r o v i d e s an a l i e n a t e d p o p u l a t i o n w i t h an o p p o r t u n i t y f o r group membership. K u r t z , (1982) i n d i s c u s s i n g t h e e x i s t e n t i a l a s p e c t s o f A . A . s u p p o r t s t h i s v i e w . D o r o f f (1977) proposes t h a t " . . . t h e p a i n o f s o b r i e t y • i s now b a l a n c e d by the rewards o f (group membership in ) A . A . " D o r o f f a l s o no te s t h a t A . A . r e g a r d s t h e d r i n k i n g problem as one p r e v i o u s l y o u t s i d e p e r s o n a l r e s p o n s i b i l i t y but r e n d e r e d a c c e s s i b l e t o p e r s o n a l w i l l . T r i c e & Roman (1970) c o n c u r , but c r i t i q u e t h i s as a b a r t o p e r s o n a l change . D o r o f f f u r t h e r no te s the a n t i - p s y c h o t h e r a p y , r e p r e s s i v e , and r e l i g i o u s a s p e c t s o f A . A . S i n c e these have been amply c r i t i c i z e d e l sewhere (eg. P a t t i s o n e t a l . , 1977) , t h e y w i l l not be c o n s i d e r e d h e r e . 70 The group membership a s p e c t o f A . A . may be an e s s e n t i a l f a c e t o f i t s t r e a t m e n t e f f e c t i v e n e s s a l t h o u g h t h e c o n t i n u i n g a v a i l a b i l i t y o f A . A . groups o v e r y e a r s cannot be r e p l i c a t e d i n t i m e - l i m i t e d t h e r a p i e s . In summary, i t appears t h a t s e l f - h e l p groups such as A . A . have e s s e n t i a l l y the same t h e r a p e u t i c compo- n e n t s as p r e v i o u s l y proposed f o r t r e a t m e n t groups i n g e n e r a l . F a c t o r s Unique t o I n d i v i d u a l Treatment C l e a r l y the e n t i r e p r a c t i c e o f c o u n s e l i n g and p s y c h o t h e r a p y has no t been swept up i n a movement toward group format . W h i l e group t r e a t m e n t appears t o have some un ique advantages i n d i v i d u a l t r e a t m e n t i s no t w i t h o u t i m p a c t . In f a c t , many o f the f a c t o r s p r o p o s e d f o r group t r e a t m e n t a r e a l s o e x p e c t e d t o e x i s t w i t h i n i n d i v i d u a l t r e a t m e n t as sugges ted above and few a r e seen t o be e x c l u s i v e . However, most o f the w r i t i n g on t h e r a p e u t i c f a c t o r s i n t r e a t m e n t has been done from the v i e w p o i n t 71 o f group t r e a t m e n t . H i s t o r i c a l l y t h i s appears t o be due t o t h e l a t e r emergence o f group format as a t r e a t - ment approach and the e f f o r t s o f t h o s e s t u d y i n g groups t o e x p l o r e and e s t a b l i s h the t h e r a p e u t i c impact o f group t r e a t m e n t w i t h r e f e r e n c e t o t h e s t a n d a r d t r e a t - ment format o f the t i m e ; i n d i v i d u a l t r e a t m e n t . As a r e s u l t most d i s c u s s i o n s o f s e p a r a t e f a c t o r s which might sugges t a p r e f e r e n c e f o r i n d i v i d u a l t r e a t m e n t appear t o be m a i n l y d i s c u s s e d w i t h i n the group t r e a t m e n t l i t e r a - t u r e . F o l l o w i n g i s a rev iew o f l i t e r a t u r e which d i s c u s s e s proposed t h e r a p e u t i c s t r e n g t h s o f i n d i v i d u a l t r e a t m e n t . K l e i n (1983) no te s t h a t i n d i v i d u a l t r e a t m e n t i s much l e s s complex i n t h a t the t h e r a p i s t i s t r e a t i n g o n l y one c l i e n t a t a t ime and i s no t i n v o l v e d i n manag- i n g an e n t i r e complex s o c i a l sys tem. Le iberman (1980) s t a t e s t h a t i n d i v i d u a l t r e a t m e n t i s p r i v a t e , i n t i m a t e , and e x c l u s i v e . He f u r t h e r p o i n t s o u t , i n agreement w i t h K l e i n , t h e a b i l i t y o f t h e t h e r a p i s t i n i n d i v i d u a l t r e a t m e n t t o c o n c e n t r a t e f u l l y on one o t h e r p e r s o n . Le iberman n o t e s t h a t i n f o c u s i n g 72 on one i n d i v i d u a l o n l y , the t h e r a p i s t c a n be i n c o n t a c t w i t h t h e c l i e n t much more i n t i m a t e l y and i n t e n s e l y o v e r a l o n g e r p e r i o d o f t i m e . He sugges t s t h a t the t y p e and d e p t h o f m a t e r i a l d i s c l o s e d may be g r e a t e r i n t h e p r e s e n c e o f a t h e r a p i s t a l o n e . Shulman (1979) emphasizes t h a t t h e t h e r a p i s t can spend more t i m e work ing on each p r e s e n t i n g prob lem i n i n d i v i d u a l t r e a t m e n t . The c l i e n t may spend as much t i m e as i s n e c e s s a r y i n d e a l i n g w i t h a prob lem and i s f r e e t o do so i n i n d i v i d u a l t r e a t m e n t where the t h e r a - p i s t may a t t e n d unimpeded by the c o n c e r n s and i n f l u e n c - es o f o t h e r s . In a d d i t i o n , Shulman o b s e r v e s , f e a r f u l , s h y , o r - u n a s s e r t i v e c l i e n t s may be more w i l l i n g t o p a r t i c i p a t e m e a n i n g f u l l y i n t h i s s e t t i n g t h a n t h e y a r e i n a g r o u p . F i n a l l y , he n o t e s , c l i e n t s w i l l be more a b l e t o a d d r e s s problems s p e c i f i c t o them r a t h e r t h a n be l i m i t e d t o d i s c u s s i n g problems w h i c h , i n some way, r e l a t e t o o t h e r group members. K o v e l (1976) sugges t s t h a t groups cannot p e r m i t e x p l o r a t i o n o f an i n d i v i d u a l ' s s u b j e c t i v e w o r l d t o t h e same l e v e l as can i n d i v i d u a l t r e a t m e n t , g i v e n t h e 73 f r e q u e n t focus o f groups on i n t e r a c t i o n s . T h i s i s s i m i l a r t o L e i b e r m a n ' s and Shulman's s ta tement above . K o v e l no te s t h a t c l i e n t s who t e n d t o o v e r - i n t e l l e c t u a l - i z e may be more a b l e t o reduce t h i s d e f e n s i v e p o s t u r e i n an i n d i v i d u a l s e t t i n g . K o v e l , s i m i l a r t o Shulman, a l s o r e f e r s t o t h e f a c t t h a t , each group forms i t s own c o l l e c t i v e c h a r a c t e r i n which some problems may be r e l e v a n t and o t h e r s n o t . As a r e s u l t , some problems i n an i n d i v i d u a l ' s l i f e may be a d d r e s s e d i n the group w h i l e o t h e r s may n o t . Thus an i n d i v i d u a l may have a p a r t i c u l a r l i f e problem which b r o u g h t him t o seek h e l p b u t w h i c h may e i t h e r not be e x p e r i e n c e d by o t h e r group members o r may not be r e l e v a n t t o the s t r u g g l e i n which t h e group i s i n v o l v e d i n the p r o c e s s o f i t s d e v e l o p - ment . Yalom (1975), i n agreement w i t h Shulman, s t a t e s t h a t a c l i e n t may f e e l s a f e r i n an i n d i v i d u a l s e t t i n g i n o r d e r t o work on some i s s u e s , o r f o r some i n d i v i d u - a l s t o work on any i s s u e s . He notes t h a t i n d i v i d u a l t r e a t m e n t may be a n e c e s s a r y t e s t i n g ground f o r s o c i a l i n v o l v e m e n t f o r some c l i e n t s f o r whom b e g i n n i n g t r e a t - ment i n a group would be i n a p p r o p r i a t e . F i n a l l y he 74 o b s e r v e s t h a t i t i s more e a s i l y p o s s i b l e t o a d d r e s s r e l a t i o n s h i p s o u t s i d e t rea tment i n i n d i v i d u a l t r e a t m e n t t h a n i t i s i n g r o u p s . I t has been p r o p o s e d t h a t f o r the above r e a s o n s an i n d i v i d u a l format may o f f e r p a r t i c u l a r advantages o v e r g r o u p t r e a t m e n t . I t a p p e a r s , t h e r e f o r e , t h a t t h e c h o i c e between the two formats i s not so e a s i l y made. Summary o f S t u d i e s Reviewed A l c o h o l consumpt ion problems are w i d e s p r e a d and c o s t l y , b o t h i n terms o f f i n a n c i a l l o s s t o our communi- t y and i n p e r s o n a l a n g u i s h . Numerous c o g n i t i v e b e h a v - i o r a l d r i n k r e d u c t i o n t r e a t m e n t s f o r problem d r i n k e r s have been d e v e l o p e d b u t few have u t i l i z e d group t r e a t - ment. Those t h a t have , found a r e s p e c t a b l e s u c c e s s r a t e . P a t t i s o n (1979) s t a t e d t h a t " . . . c o n t r o l l e d s t u d i e s have p r o v i d e d no s u p p o r t f o r the p o p u l a r b e l i e f t h a t g r o u p methods r e p r e s e n t a s u p e r i o r approach ( P . 5 7 ) " but i n d i c a t e d t h a t a wide range o f t r ea tment t e c h n i q u e s and 75 p o o r e x p e r i m e n t a l d e s i g n s p r e v e n t t h e drawing o f g e n e r a l c o n c l u s i o n s . M i l l e r e t a l . (1981) u t i l i z e d a group t rea tment p s y c h o e d u c a t i o n a l approach w i t h f a v o r - a b l e r e s u l t s but w i t h o u t a c o n t r a s t t o i n d i v i d u a l t r e a t m e n t . L a t e r M i l l e r & T a y l o r (1980) c o n t r a s t e d group and i n d i v i d u a l t r ea tment u s i n g t h e same p s y c h o e d u c a t i o n a l package . Group and i n d i v i d u a l t r e a t m e n t s were found t o be e q u a l l y e f f e c t i v e . W h i l e t h e M i l l e r and T a y l o r s t u d y s u c c e s s f u l l y c o n t r o l l e d f o r d i f f e r e n c e s i n c o n t e n t between c o n d i t i o n s , which was a major c r i t i c i s m o f p r e v i o u s group v e r s u s i n d i v i d u a l c o n t r a s t s , the exper iment was s e v e r e l y f l a w e d . Group t r e a t m e n t r e c e i v e d a lmost double the t r e a t m e n t t ime o f i n d i v i d u a ' l t r e a t m e n t , t h e r a p i s t s were no t d i s t r i b u t e d a c r o s s c o n d i t i o n s , and group members were n o t randomly a s s i g n e d . In a d d i t i o n t h e t rea tment c o n d i t i o n s d i f - f e r e d w i d e l y from each o t h e r on a l c o h o l consumpt ion a t p r e t e s t and d a t a was m i s s i n g on f o l l o w - u p consumpt ion f i g u r e s f o r about h a l f o f the s u b j e c t s . A r e p l i c a t i o n and e x t e n s i o n seems a p p r o p r i a t e . S o c i a l p s y c h o l o g i s t s have found t h a t s e v e r a l f a c t o r s c o n t r i b u t e t o a p o s s i b l e added e f f i c a c y o f 76 group f o r m a t . Peer i n f l u e n c e was found by A s c h (1952) and o t h e r s t o have a s i g n i f i c a n t impact on p e r c e p t i o n and judgment. F e s t i n g e r ( F e s t i n g e r & C a r l s m i t h , 1959) and o t h e r s found t h a t p u b l i c p r e s e n t a t i o n s o f i n c o n s i s - t e n c i e s i n a t t i t u d e s r e s u l t e d i n d i s c o m f o r t . F u r t h e r , t h e y found t h a t t h i s d i s c o m f o r t was r e s o l v e d by a s h i f t i n a t t i t u d e s toward e n d o r s i n g t h a t which had been p u b l i c l y p r e s e n t e d w i t h l i t t l e a p p a r e n t p a y o f f . V i n o k u r (1971) and o t h e r s found t h a t groups e x h i b i t a t endency t o endorse the more r i s k y o f p r o b l e m s o l u t i o n s w i t h group d e c i s i o n making. The s o c i a l p s y c h o l o g i c a l l a b o r a t o r y r e s e a r c h i m p l i e s t h a t , i n an a l c o h o l t r e a t m e n t c o n t e x t ; (1) p e e r i n f l u e n c e w i l l s i g n i f i c a n t l y shape a t t i t u d e s i n t h e d i r e c t i o n o f the group consensus , wh ich i s p r e d e - t e r m i n e d by v o l u n t e e r i n g f o r a d r i n k r e d u c t i o n t r e a t - ment t o be s e l f - s e l e c t e d i n d i v i d u a l s who endorse the g o a l o f r educed a l c o h o l c o n s u m p t i o n , (2) t h a t the p u b l i c endorsement o f these g o a l s w i t h i n t h e group w i l l f u r t h e r e n t r e n c h the changed a t t i t u d e s , and (3) t h a t t h e group movement w i l l be i n t o more and more r i s k y d r i n k r e d u c t i o n g o a l s and ach ievement . 77 A p p l i e d s o c i a l p s y c h o l o g y r e s e a r c h i n d i c a t e d t h a t m o d e l i n g and s o c i a l i n f l u e n c e were an i m p o r t a n t c o n - t r i b u t i n g f a c t o r t o consumption o f a l c o h o l and c i g a - r e t t e s . E i s e r (1985) p r o p o s e d a s o c i a l i n f l u e n c e model i n which s o c i a l i d e n t i t y t o a p r i m a r y s o c i a l group i s a key f a c t o r and r e s t s upon g i v i n g i n f l u e n c e p o t e n t i a l t o t h i s group i n a t t r i b u t i n g t o i t (1) t h e s t a n d a r d s f o r s e l f e v a l u a t i o n , (2) the major d a t a s o u r c e f o r r e l e v a n t i n f o r m a t i o n , (3) and the major s o u r c e o f e x p e c t a n c i e s about an a c t i v i t y . The a p p l i e d and l a b o r a t o r y s o c i a l p s y c h o l o g i c a l m a t e r i a l i m p l i e s t h a t group t r e a t m e n t w i l l (1) i n f l u - ence r e d u c e d d r i n k i n g b e h a v i o r by mutua l m o d e l l i n g as weekly g o a l s a r e s e t and a c h i e v e d , and (2) p r o v i d e a t r e a t m e n t r e f e r e n c e group t h a t w i l l become a source o f s o c i a l i d e n t i t y w i t h i t s open d i s c u s s i o n o f s t a n d a r d s , r e l e v a n t i n f o r m a t i o n and e x p e c t a n c i e s and thus w i l l i n f l u e n c e b e h a v i o r i n the d i r e c t i o n o f t h e r e d u c t i o n o f consumpt ion toward s t a t e d g o a l s . Group t r e a t m e n t r e s e a r c h sugges t s t h a t a number o f t h e r a p e u t i c f a c t o r s a r e a s s o c i a t e d w i t h t r e a t m e n t 78 g a i n s . S e v e r a l d i f f e r e n t t h e o r i s t s have d e v e l o p e d c l o s e l y i n t e r r e l a t e d l i s t s o f t h e r a p e u t i c f a c t o r s . B l o c h e t a l . (1981) d e v e l o p e d one o f t h e most r e c e n t l i s t s and h i s was c l o s e l y r e l a t e d t o t h a t deve loped by Yalom (1975) which s e r v e s as one o f t h e p r i m a r y r e f e r - ence p o i n t s i n t h e f i e l d . Thus t h e i r models a r e used h e r e i n t e r c h a n g e a b l y . B l o c h ' s t h e r a p e u t i c f a c t o r s a r e : (1) s e l f - d i s c l o s u r e , (2) i n t e r a c t i o n , (3) a c c e p t a n c e o r c o h e s i v e n e s s , (4) i n s i g h t , (5) c a t h a r s i s , (6) g u i d a n c e , (7) u n i v e r s a l i t y , (8) a l t r u i s m , (9) v i c a r i o u s l e a r n i n g , (10) i n s t i l l a t i o n o f hope, and (11) an e x i s t e n t i a l f a c t o r . When t h e s e f a c t o r s a r e c r i t i c a l l y r e v i e w e d , i t becomes a p p a r e n t t h a t most o f them a r e a v a i l a b l e and a c t i v e i n b o t h i n d i v i d u a l t r e a t m e n t and group t r e a t - ment. The e x c e p t i o n s a r e : i n t e r a c t i o n , c o h e s i v e n e s s , u n i v e r s a l i t y , a l t r u i s m , and v i c a r i o u s l e a r n i n g . These d i s t i n c t i v e f a c t o r s t h e n become the c r i t i c a l f a c t o r s by w h i c h group and i n d i v i d u a l t r e a t m e n t s a r e s a i d t o d i f f e r and t h e ones t o which a l l u n i q u e a d d i t i o n a l g a i n s by group t r e a t m e n t must be a t t r i b u t e d . These a r e n o t t h e f a c t o r s which have been proposed t o be t h e most 79 p o w e r f u l t h e r a p e u t i c components o f a group b u t they a r e t h o s e by which the two t rea tment s can be d i s t i n g u i s h e d . A s e l f h e l p group i n common use , A l c o h o l i c s Anonymous i s a l s o r e v i e w e d . Important t h e r a p e u t i c f a c t o r s a v a i l a b l e appear t o be: group c o h e s i v e n e s s , c o n f r o n t a t i o n ( s i m i l a r t o B l o c h ' s i n s i g h t and e x i s t e n - t i a l f a c t o r s ) , u n i v e r s a l i t y , and s e l f d i s c l o s u r e as t h e most i m p o r t a n t f a c t o r s . S o c i a l P s y c h o l o g y t h e o r i e s o f group i n f l u e n c e would a p p e a r t o sugges t t h a t the most s a l i e n t o f t h e f a c t o r s u n i q u e t o groups a r e i n t e r a c t i o n , c o h e s i v e n e s s and v i c a r i o u s l e a r n i n g ( u s i n g t h i s f a c t o r t o i n c l u d e m o d e l i n g ) . I n t e r a c t i o n would p r o v i d e the raw m a t e r i a l f o r t h e development o f group c o h e s i o n which would , by i m p l i c a t i o n from the r e s e a r c h o f the v a r i o u s s o c i a l p s y c h o l o g i s t s above, i n t e r a c t i n the c o n t e x t o f an u r g e t o be p a r t o f and c o n s i s t e n t w i t h a r e f e r e n c e g r o u p . P a r t o f t h e impact o f t h i s group would be e x e r t e d by o b s e r v i n g o t h e r s ' i n t e r a c t i o n s and t h u s e x t r a p o l a t i n g g u i d e s f o r b e h a v i o r , and p a r t by m o d e l i n g o t h e r s ' b e h a v i o r s . 80 C o n c l u s i o n T h e r e a r e ample t h e o r e t i c a l s u g g e s t i o n s t h a t group t r e a t m e n t would have un ique and a d d i t i o n a l impact when c o n t r a s t e d w i t h i n d i v i d u a l t r e a t m e n t . P r e v i o u s r e - s e a r c h a t t e m p t i n g t h i s c o n t r a s t has been s e v e r e l y l i m i t e d by d e s i g n prob lems , p a r t i c u l a r l y t h o s e which confounded t rea tment format (group o r i n d i v i d u a l ) w i t h t r e a t m e n t c o n t e n t . The l i t e r a t u r e o f s t u d i e s c o n t r a s t - i n g groups and i n d i v i d u a l formats i s about e q u a l l y d i v i d e d between those f i n d i n g one o r t h e o t h e r t o be more e f f e c t i v e o r b o t h t o be about e q u a l i n i m p a c t . However, t h i s t o t a l o f p r e v i o u s r e s e a r c h i s i t s e l f s u s p e c t because the s t u d i e s upon which i t i s based a r e themse lves f a u l t y . D e f i n i t i v e work which c o n t r o l s f o r t r e a t m e n t c o n t e n t i n a c o n t r a s t o f group and i n d i v i d u a l formats i s y e t t o be done. T h e o r e t i c a l f a c t o r s proposed t o e x i s t i n group t r e a t m e n t s g e n e r a l l y appear i n i n d i v i d u a l t r e a t m e n t , w i t h the e x c e p t i o n o f f i v e f a c t o r s . These t h e n become t h e c r i t i c a l f a c t o r s by which group t r e a t m e n t i s s a i d t o be d i f f e r e n t from and s u p e r i o r t o i n d i v i d u a l 81 t r e a t m e n t . A p r e v i o u s e f f o r t ( M i l l e r & T a y l o r , 1980) a t c o n t r a s t i n g group and i n d i v i d u a l t r e a t m e n t s u t i l i z - i n g a s t r u c t u r e d c o n t r o l l e d d r i n k i n g program t h a t c o n t r o l l e d f o r c o n t e n t d i f f e r e n c e s a c r o s s f o r m a t s was q u i t e f lawed i n i t s d e s i g n . An a d d i t i o n a l p r o b l e m w i t h t h i s r e s e a r c h was t h a t the s u b j e c t groups were w i d e l y d i f f e r e n t a t the o u t s e t on the major t r e a t m e n t v a r i a b l e o f a l c o h o l consumpt ion . A r e p l i c a t i o n and e x t e n s i o n o f t h i s s t u d y w i t h the d e s i g n f laws remedied i s i n o r d e r as i t would p r o v i d e the o p p o r t u n i t y f o r an a c c u r a t e c o n t r a s t o f group and i n d i v i d u a l format w i t h r e g a r d t o t h e r a p e u t i c e f f i c a c y . Purpose and Hypotheses The purpose o f the c u r r e n t s t u d y i s t o t e s t t h e d i f f e r e n c e i n t h e r a p e u t i c impact between group and i n d i v i d u a l formats i n t r e a t i n g problem d r i n k i n g . Group and i n d i v i d u a l t r e a t m e n t methods a r e c o n t r a s t e d u s i n g t h e same s t r u c t u r e d p s y c h o e d u c a t i o n a l t r e a t m e n t package i n b o t h formats t o c o n t r o l f o r t r e a t m e n t c o n t e n t . The s u b j e c t s are e a r l y problem d r i n k e r s t a k i n g p a r t i n t r e a t m e n t w i t h the g o a l o f reduced a l c o h o l c o n s u m p t i o n . 82 The Research Hypotheses a r e : Group treatment format w i l l be s u p e r i o r t o i n d i - v i d u a l format , l e a d i n g t o g r e a t e r r e d u c t i o n i n a l c o h o l consumption and g r e a t e r improvements i n s o c i a l f u n c t i o n i n g . T h i s d i f f e r e n c e i s proposed t o be the r e s u l t o f added f a c t o r s p r e s e n t i n group but not i n d i v i d u a l t r e a t m e n t . These a d d i t i o n a l t h e r a p e u t i c compo- nents have been proposed t o be i n t e r a c t i o n , c o h e s i v e n e s s , and v i c a r i o u s l e a r n i n g . Both group and i n d i v i d u a l format t rea tments w i l l be s u p e r i o r t o a w a i t l i s t c o n t r o l c o n d i t i o n i n showing a g r e a t e r r e d u c t i o n i n a l c o h o l consumption and g r e a t e r improvement i n s o c i a l f u n c t i o n i n g . The Program d e s i g n e d f o r t h i s s t u d y was a h i g h l y s t r u c t u r e d and compact i n t e r v e n t i o n drawing on the work o f s e v e r a l r e s e a r c h e r s . I t was proposed t h a t i t would be a power fu l i n t e r v e n t i o n i n a s s i s t i n g c l i e n t s i n c o n t r o l l i n g t h e i r a l c o h o l consumpt ion . 83 F o r p u r p o s e s o f t e s t i n g these h y p o t h e s e s , p r i m a r y and s e c o n d a r y measures were used t o a s se s s t r e a t m e n t g a i n : (1) p r i m a r y treatment measures: weekly a l c o h o l consumpt ion and peak day a l c o h o l c o n s u m p t i o n , (2) s e c o n d a r y treatment measures: s e l f - r e p o r t o f prob lem s e v e r i t y , r e c e n t mood, and s o c i a l a d j u s t - ment. 84 CHAPTER 3 Methodology Overv iew T h i s c h a p t e r opens w i t h a d i s c u s s i o n o f t h e e x p e r i m e n t a l d e s i g n chosen t o t e s t the hypotheses o f t h e c u r r e n t s t u d y . A d i s c u s s i o n o f the s p e c i f i c p r o c e d u r e s o f t h i s s t u d y i s f o l l o w e d by a d i s c u s s i o n about the s u b j e c t s o f the s t u d y , and the m a t e r i a l s u s e d i n t h e s t u d y . E x p e r i m e n t a l Des ign The d e s i g n s employed i n t h i s s tudy were: (1) a p r e - t e s t p o s t - t e s t compar i son o f t r ea tment c o n d i t i o n s f o r c o n t r a s t s r e l e v a n t t o t h e f i r s t h y p o t h e s i s o f t h e s t u d y ( H o i : Groups w i l l be more i m p a c t f u l t h a n i n d i - v i d u a l format t rea tment ) and i n which the i n d i v i d u a l t r e a t m e n t s e r v e d as a c o n t r o l c o n d i t i o n , and (2) a p r e - t e s t p o s t - t e s t compar i son o f t r e a t m e n t and a c o n t r o l c o n d i t i o n f o r the second h y p o t h e s i s o f t h e 85 s t u d y (Ho2: Treatment w i l l be more i m p a c t f u l t h a n no t r e a t m e n t ) . These may be i l l u s t r a t e d as f o l l o w s : H o i : R 0 l X l 0 2 0 3 R ° 4 X 2 ° 5 ° 6 Where R i n d i c a t e s random ass ignment o f s u b j e c t s , X i n d i c a t e s a t r e a t m e n t , and 0 i n d i c a t e s t e s t i n g u s i n g t h e r e s e a r c h measures and i n c l u d e s the p r e - t e s t , the p o s t - t e s t , and the s i x month f o l l o w - u p p o s t - t e s t . In t h i s d e s i g n a l l s u b j e c t s a r e randomly a s s i g n e d t o one o f the two t r e a t m e n t c o n d i t i o n s , each o f which r e c e i v e a d i f f e r e n t t r e a t m e n t f o r m a t . 'Measures a r e t h e n c o l l e c t e d f o r a l l s u b j e c t s a t t h e end o f t r e a t m e n t . Measures a r e a g a i n t a k e n s i x months l a t e r . Ho2: R 0 1 X Q>2 R ° 3 ° 4 In t h i s second d e s i g n a l l s u b j e c t s were randomly a s s i g n e d t o one o f two c o n d i t i o n s . The f i r s t c o n d i t i o n r e c e i v e d t r e a t m e n t w h i l e the second s e r v e d as a w a i t l i s t c o n t r o l c o n d i t i o n . Measures were t h e n c o l l e c t e d f o r a l l s u b j e c t s a t t h e p o s t - c o n d i t i o n p o s i t i o n . 86 The purpose o f a c o n t r o l c o n d i t i o n i n t h e above d e s i g n s was t o p r o v i d e an independent assessment o f the s t a b i l i t y o f a t a r g e t b e h a v i o r when an i n t e r v e n t i o n d i r e c t e d toward t h a t b e h a v i o r i s not g i v e n . W h i l e c o n t r o l groups a r e a f r e q u e n t demand o f r i g o r o u s r e s e a r c h i t has been p o i n t e d out on o c c a s i o n t h a t t h e y may be u n n e c e s s a r y g i v e n the e x t r e m e l y common f i n d i n g o f b e h a v i o r a l s t a b i l i t y . Campbel l and S t a n l e y (1963) recommend t h e s e d e s i g n s as t r u e e x p e r i m e n t a l d e s i g n s . In t h e use o f t h i s d e s i g n t h e y recommend t h a t g a i n - s c o r e s , t h e changes between the p r e - t e s t measure and the p o s t - t e s t measure , be a v o i d e d as t h i s may a r t i f i c i a l l y s u p p o r t a s i g n i f i c a n t d i f f e r e n c e , p a r t i c u l a r l y i f t h e g a i n o f t h e c o n t r o l c o n d i t i o n i s n e a r s i g n i f i c a n c e . R a t h e r t h e y sugges t t h a t t h e p r e - t e s t s c o r e s be u t i l i z e d t o form b l o c k s o r t h a t they be used as c o v a r i a t e s f o r the p o s t - t e s t s c o r e c o m p a r i s o n s , as i n the c u r r e n t s t u d y . W h i l e the d e s i g n u t i l i z e d a common s u b j e c t p o o l , the i n c l u s i o n o f some s u b j e c t s i n more t h a n one c o n d i t i o n n e c e s s i t a t e d t h e d i v i s i o n o f the d e s i g n s and s t a t i s t i c a l a n a l y s e s i n t o the s e p a r a t e h y p o t h e s i s . T h i s w i l l be d i s - c u s s e d more f u l l y below i n t h e p r o c e d u r e s s e c t i o n . 87 S u b j e c t s P o p u l a t i o n s and Samples The t a r g e t p o p u l a t i o n o f t h i s s t u d y was e a r l y s tage p r o b l e m d r i n k e r s . The a c c e s s i b l e p o p u l a t i o n c o n s i s t e d o f e a r l y s t a g e prob lem d r i n k e r s i n a m o d e r a t e l y s i z e d c i t y . The a c t u a l sample c o n s i s t e d o f v o l u n t e e r s f o r t r e a t m e n t a t a c o n t r o l l e d d r i n k i n g c l i n i c who responded t o a newspaper a d v e r t i s e m e n t f o r t h i s c l i n i c and met s e v e r a l s c r e e n i n g c r i t e r i a . R e c r u i t m e n t and S e l e c t i o n S u b j e c t s were s creened b r i e f l y d u r i n g an i n i t i a l t e l e p h o n e i n t e r v i e w , d u r i n g a f a c e - t o - f a c e i n t e r v i e w , and a f t e r r e c e i p t o f a m e d i c a l r e p o r t ( M e d i c a l S c r e e n i n g ; A p p e n d i x A ) . The purpose o f the s c r e e n i n g was t o d i v e r t from t h e s e t r e a t m e n t s any i n d i v i d u a l s who: (1) had m e d i c a l c o n t r a i n d i c a t i o n s t o c o n t i n u e d but reduced a l c o h o l consump- t i o n : (2) appeared t o have more s e v e r e o r e x t e n s i v e p r o b - lems i n t h e a r e a s o f c a r e e r , s o c i a l i n t e g r a t i o n , o r r e l a - t i o n s h i p due t o . a l c o h o l problems ( s e v e r a l j o b l o s s e s , f r i e n d s h i p d i s i n t e g r a t i o n s , or m a r i t a l d i s r u p t i o n due t o 88 a l c o h o l i n v o l v e m e n t ) : (3) appeared t o be p h y s i o l o g i c a l l y a d d i c t e d t o a l c o h o l from the amount o f consumption r e p o r t e d ( i . e . 60 o r more d r i n k s p e r week): (4) had a l e n g t h y d u r a t i o n o f d r i n k i n g problem (ten y e a r s o r more) : o r (5) had p r e v i o u s and u n s u c c e s s f u l t r e a t m e n t s f o r a l c o h o l c o n - sumpt ion problems ( e s p e c i a l l y i n p a t i e n t t r e a t m e n t s ) . A p p r o x i m a t e l y h a l f o f the t o t a l number o f s u b j e c t s t o t h e program were d i v e r t e d a t the t e l e p h o n e i n t e r v i e w o r f a i l e d t o a t t e n d s c r e e n i n g appo in tments . Two i n d i v i d u a l s were d i v e r t e d from t r e a t m e n t i n t h i s program as t h e r e s u l t o f a f a c e - t o - f a c e i n t e r v i e w o r m e d i c a l a d v i c e . One was r e f e r r e d t o an a b s t i n e n c e program and one t o a p s y c h i a t r i s t . F i n a l l y , <one c o u p l e and two s i b l i n g s e n t e r e d t r e a t m e n t t o g e t h e r and were thus p l a c e d randomly as a u n i t i n t h e same t r e a t m e n t c o n d i t i o n , t h a t o f the group c o n d i t i o n . T h i r t y - e i g h t s u b j e c t s p a r t i c i p a t e d i n the e x p e r i m e n t a l program f o r e a r l y s tage problem d r i n k e r s . As i n d i c a t e d above , some s u b j e c t s were i n c l u d e d i n more than one c o n d i - t i o n , t h a t i s they appeared i n a w a i t - l i s t c o n t r o l c o n d i - t i o n , and were then i n v i t e d t o p a r t i c i p a t e i n t r e a t m e n t and t h u s appeared i n a t r e a t m e n t c o n d i t i o n as w e l l . As a r e s u l t o f t h i s maneuver t h e r e were s i x t e e n s u b j e c t s i n each 89 c o n d i t i o n o f group t r e a t m e n t , i n d i v i d u a l t r e a t m e n t , and t h e w a i t - l i s t c o n t r o l c o n d i t i o n . T h e r a p i s t s Two t h e r a p i s t s p a r t i c i p a t e d i n the s t u d y . One was female and a t h e r a p i s t o f c o n s i d e r a b l e e x p e r i e n c e i n t r e a t - i n g s u b s t a n c e abuse d i s o r d e r s . She was a l s o a s t a f f t r a i n e r f o r t h e p r o v i n c i a l agency mandated t o t r e a t s u b s t a n c e abuse d i s o r d e r s . The o t h e r was male , a l s o w i t h c o n s i d e r a b l e e x p e r i e n c e i n the t r e a t m e n t o f subs tance abuse d i s o r d e r s , and was the c l i n i c c o o r d i n a t o r and s u p e r v i s o r o f t h e c l i n i c s i t e o f the s t u d y . Both r e c e i v e d the same b r i e f i n g and t r a i n i n g 'program manual t o f o l l o w . C l i e n t s i n t h e t r e a t m e n t c o n d i t i o n s were s p l i t so t h a t each t h e r a p i s t t r e a t e d h a l f o f each c o n d i t i o n . P r o c e d u r e Trea tment C o n d i t i o n s The c u r r e n t s tudy was c o n s t r u c t e d t o t e s t two s e p a r a t e h y p o t h e s e s . The f i r s t and major h y p o t h e s i s o f i n t e r e s t was t h a t group t r e a t m e n t would be more e f f e c t i v e t h a n was i n d i v i d u a l t r e a t m e n t . T h i s was t e s t e d by o p e r a t i n g two 90 t r e a t m e n t c o n d i t i o n s w i t h the same c o n t e n t b u t v a r y i n g on group o r i n d i v i d u a l format . The r e l a t i v e e f f i c a c y o f t h e two formats was a s s e s s e d by s t a t i s t i c a l c o n t r a s t s o f p o s t - t e s t measures o f a l c o h o l consumpt ion , l i f e s t y l e p r o b l e m s e v e r i t y , mood, and s o c i a l a d j u s t m e n t . The second h y p o t h e s i s o f i n t e r e s t was t h a t t r e a t m e n t would be more e f f e c t i v e than would be no t r e a t m e n t . T h i s h y p o t h e s i s was t e s t e d by o p e r a t i n g a n o t h e r c o n d i t i o n , t h a t o f a w a i t - l i s t c o n t r o l group who d i d not r e c e i v e t r e a t m e n t p r i o r t o p o s t - t e s t . The e f f i c a c y o f t r e a t m e n t was a s s e s s e d by s t a t i s t i c a l c o n t r a s t s between t h o s e s u b j e c t s who had r e c e i v e d t r e a t m e n t and those who were i n the n o - t r e a t m e n t c o n d i t i o n on a l c o h o l consumption measures . Both t r e a t m e n t c o n d i t i o n s were e i g h t weeks i n l e n g t h and c o n s i s t e d o f once-weekly meet ings o f 1.25 h o u r s e a c h . C l i e n t s i n each c o n d i t i o n were unaware o f t h e e x i s t e n c e o f t h e o t h e r c o n d i t i o n s and c l i n i c appo intments were a r r a n g e d so t h a t the o t h e r c o n d i t i o n s d i d not meet t h o s e o f t h e o t h e r s . W a i t - l i s t c l i e n t s were unaware, f o r t h e d u r a t i o n o f t h e e x p e r i m e n t , t h a t they were a s s i g n e d t o t h i s c o n t r o l group c o n d i t i o n . The n a t u r e o f the p r o c e d u r e s were e x - p l a i n e d t o the c l i e n t s a t the end o f t h e i n d i v i d u a l ' s p a r t i c i p a t i o n . 91 Review o f D e s i g n The d e s i g n c o n s i s t e d o f p o s t - t e s t c o m p a r i s o n s o f d i f f e r e n t e x p e r i m e n t a l c o n d i t i o n s . The s t a t i s t i c a l p r o c e - d u r e u t i l i z e d was a n a l y s e s o f c o v a r i a n c e , which used the p r e - t e s t p o s i t i o n on each o f the measures t e s t e d as the c o v a r i a t e i n t h e c o n t r a s t o f t h a t p o s t - t e s t measure . T h i s a l l o w e d c o r r e c t i o n s f o r i n d i v i d u a l d i f f e r e n c e s so t h a t d i f f e r e n c e s due t o t h e t r e a t m e n t c o n d i t i o n s t h e m s e l v e s c o u l d be more d i s c e r n i b l e and a d j u s t e d f o r wide i n i t i a l i n d i v i d u a l d i f f e r e n c e s . The p r o j e c t p r o c e d u r e s can b e s t be d e s c r i b e d w i t h i n t h e c o n t e x t o f t h e h i s t o r y o f the f i e l d s t u d y . W i t h i n t h i s framework i t i s p o s s i b l e t o d i s c u s s the numerous un ique f a c e t s o f t h i s p a r t i c u l a r e x p e r i m e n t . T h i s w i l l be p r e s e n t - ed i n Des ign Adjus tments and S t a t i s t i c a l C o n s i d e r a t i o n s be low. C o n t a c t and S e l e c t i o n o f C l i e n t s An a d v e r t i s e m e n t (Appendix B) was p l a c e d i n t h e l o c a l l a r g e - s u b s c r i p t i o n newspaper weekend e d i t i o n . F o l l o w i n g t h i s , a p p l i c a n t s t o the program began t o t e l e p h o n e t o e n q u i r e about the program and were p l a c e d a l t e r n a t e l y i n t o 92 one o f t h e t h r e e c o n d i t i o n s : group f o r m a t , i n d i v i d u a l f o r m a t , o r t h e c o n t r o l group c o n d i t i o n . An i n i t i a l t e l e - phone s c r e e n i n g was g i v e n which i n c l u d e d t a k i n g a l c o h o l consumpt ion d a t a and g i v i n g i n i t i a l i n f o r m a t i o n about t h e t r e a t m e n t c o n d i t i o n t o which t h e c l i e n t had been a s s i g n e d . F o r t h o s e who s a t i s f i e d the i n i t i a l s c r e e n i n g c r i t e r i a f o r t h e c l i n i c an appointment was made f o r a p e r s o n a l i n t e r v i e w w i t h t h e p r o s p e c t i v e c l i e n t and h i s o r h e r s i g n i f i c a n t o t h e r , i f a v a i l a b l e (See C l i e n t Consent Form, Appendix C ) . Random Ass ignment A l t e r n a t e ass ignment a t f i r s t c o n t a c t t o the t r e a t m e n t c o n d i t i o n s was chosen as a method o f random ass ignment s i n c e a p p l i c a n t e n q u i r i e s were r e c e i v e d on a random b a s i s and n o t h i n g was known about the a p p l i c a n t s a t t h e t ime o f a s s i g n m e n t . Those i n the w a i t - l i s t c o n t r o l group c o n d i t i o n were a s s i g n e d t o be t r e a t e d a t t h e c o m p l e t i o n o f the c o n t r o l group p e r i o d as an e t h i c a l c o n s i d e r a t i o n . D u r i n g the e i g h t week w a i t - l i s t p e r i o d these i n d i v i d u a l s had no c o n t a c t w i t h t h e c l i n i c . A t the end o f the w a i t - l i s t p e r i o d they were r e - a s s e s s e d w i t h r e g a r d t o the consumpt ion v a r i a b l e s and t h e n p l a c e d i n t o t r e a t m e n t . 93 W h i l e i t was o r i g i n a l l y i n t e n d e d t h a t the c o n d i t i o n s would be f i l l e d through t h i s a l t e r n a t e ass ignment , i t soon became a p p a r e n t t h a t t h i s was not p o s s i b l e s i n c e fewer a p p l i e d t o t h e program than were expec ted and s i n c e about h a l f o f t h o s e who a p p l i e d were judged t o be i n a p p r o p r i a t e b a s e d on t h e p r e v i o u s l y e x i s t i n g a d m i s s i o n c r i t e r i a f o r t h e c l i n i c ( c o n s i s t e n t w i t h p r e v i o u s c l i n i c t r e n d s ) . C o l l a t e r a l V e r i f i c a t i o n by S i g n i f i c a n t O t h e r s S i g n i f i c a n t o t h e r s were i n v i t e d t o a t t e n d the f i r s t p e r s o n a l i n t e r v i e w and p o s t - t r e a t m e n t and f o l l o w - u p i n t e r - v i e w s . They were p r e s e n t d u r i n g the assessment i n t e r v i e w and were -asked t o v a l i d a t e o r c o r r e c t the c l i e n t ' s r e p o r t e d c o n s u m p t i o n and h i s o r h e r r e p o r t s o f o t h e r r e l a t e d p r o b - lems . The use o f s i g n i f i c a n t o t h e r s i n some s t u d i e s has been a g r e a t d e a l more i n v o l v e d than i n t h i s s tudy i n l i g h t o f a commonly a c c e p t e d b e l i e f t h a t persons w i t h a l c o h o l consump- t i o n prob lems r o u t i n e l y m i s r e p r e s e n t t h e i r c o n s u m p t i o n . However, w i t h s i m i l a r samples and programs and w i t h the use o f v e r y e x a c t i n g v a l i d a t i o n checks t h e most f r e q u e n t f i n d i n g i n t h e l i t e r a t u r e i s t h a t t h e s e i n d i v i d u a l s c o r r e c t l y r e p o r t t h e i r a l c o h o l consumpt ion , i n c o n t r a d i c t i o n t o the commonly h e l d b e l i e f t h a t s i m i l a r p e o p l e w i l l a lways m i s r e p r e s e n t t h e m s e l v e s . A summary o f t h i s l i t e r a t u r e i s i n c l u d e d i n Appendix D. T h u s , the d e c i s i o n was made t o use s i g n i f i c a n t o t h e r s i n t h e f a s h i o n d e s c r i b e d above. D e s i g n Adjus tment s Treatment s t a r t s were s t a g g e r e d , i n t h a t , c l i e n t s began t r e a t m e n t a t d i f f e r e n t t i m e s depending on the a v a i l a b i l i t y o f c l i e n t s and t h e r a p i s t s as w e l l as the c o m p l e t i o n o f s c r e e n i n g p r o c e d u r e s . A t t h e p o i n t where in i t was d i s c o v e r e d t h a t fewer s u b j e c t s than were expected were a v a i l a b l e , t h e f i r s t group o f the group t r e a t m e n t had begun t r e a t m e n t and s e v e r a l i n d i v i d u a l s i n the i n d i v i d u a l t r e a t m e n t c o n d i t i o n had a l s o begun t r e a t m e n t . S e v e r a l w a i t - l i s t c l i e n t s had a l s o begun t h e i r w a i t - l i s t p e r i o d o f e i g h t weeks. I n t e r - v i ews and some i n i t i a l s c r e e n i n g were s t i l l p r o c e e d i n g w i t h most o f the remainder o f t h e s u b j e c t p o o l and some a p p l i c a - t i o n s t o t h e program were s t i l l b e i n g r e c e i v e d , a l t h o u g h a t a much r e d u c e d f r e q u e n c y . In view o f t h i s , t h e d e c i s i o n was made t o p l a c e a l l r e m a i n i n g c l i e n t s , who had a l r e a d y been in formed about t h e i r a s s i g n e d t rea tment c o n d i t i o n , i n t o the w a i t - l i s t c o n d i t i o n f i r s t , once i n t e r v i e w s were comple te w i t h each , and t h e n t o p l a c e them i n t o t h e i r p r e v i o u s l y a s s i g n e d t r e a t m e n t c o n d i t i o n upon c o m p l e t i o n o f the w a i t - 95 l i s t p e r i o d and r e - t e s t i n g . T h i s a l l o w e d each c o n d i t i o n t o have s i x t e e n c l i e n t s p e r c e l l , a l t h o u g h i t n e c e s s i t a t e d some changes i n the d a t a a n a l y s e s . The t i m i n g o f t h i s d e c i s i o n r e s u l t e d i n one c l i e n t from the group c o n d i t i o n and n i n e from the i n d i v i d u a l c o n d i t i o n b e i n g p l a c e d onto t h e w a i t - l i s t p r i o r t o e n t r y i n t o t h e i r p r e - a s s i g n e d t r e a t m e n t c o n d i t i o n . S t a t i s t i c a l C o n s i d e r a t i o n s As noted above, t h i s d e s i g n adjus tment n e c e s s i t a t e d changes i n the d a t a a n a l y s e s . S p e c i f i c a l l y , t h e s t a t i s t i c a l a n a l y s e s adjus tments r e q u i r e d were t w o f o l d . (1) F i r s t l y , t h e c l i e n t s who appeared i n b o t h the w a i t - l i s t and t h e t r e a t m e n t c o n d i t i o n s were e l i m i n a t e d from c o n s i d e r a t i o n i n one o f these c e l l s so t h a t they would not be compared w i t h t h e m s e l v e s w i t h i n t h e same a n a l y s i s . T h u s , w h i l e each c o n d i t i o n had s i x t e e n c l i e n t s , the d a t a a n a l y s e s o f t h e f i r s t h y p o t h e s i s , t h a t group t r e a t m e n t would be more e f f e c - t i v e than i n d i v i d u a l t r e a t m e n t , u t i l i z e d s i x t e e n c l i e n t s each from b o t h the group c o n d i t i o n and the i n d i v i d u a l c o n d i t i o n but d i d not use the w a i t - l i s t d a t a w h i c h , a f t e r a l l , was not c e n t r a l t o the h y p o t h e s i s t e s t e d . S i m i l a r l y , t h e d a t a a n a l y s i s o f the second h y p o t h e s i s , t h a t t r e a t m e n t u s i n g the p r e s e n t program would be more e f f e c t i v e t h a n an 96 e q u i v a l e n t d u r a t i o n w a i t - l i s t , used s i x t e e n c l i e n t s from the w a i t - l i s t , and twenty-two c l i e n t s from the two t r e a t m e n t c o n d i t i o n s . Ten were e l i m i n a t e d from t h e t r e a t m e n t c o n d i - t i o n s as t h e y a l s o appeared i n the d a t a s e t f o r the w a i t - l i s t c o n d i t i o n . (2) S e c o n d l y , s t a t i s t i c a l c o n t r a s t s were r e q u i r e d t o ensure t h a t b e i n g p l a c e d on a w a i t - l i s t p r i o r t o t r e a t m e n t d i d not s y s t e m a t i c a l l y b i a s the outcomes i n c o n t r a s t t o t h o s e who d i r e c t l y e n t e r e d t r e a t m e n t . A t t h e same t i m e d a t a a n a l y s e s were performed t o ensure t h a t t h e two groups o f the group c o n d i t i o n were s i m i l a r . T h u s , a number o f d a t a a n a l y s e s were c a r r i e d out p r i o r t o t h e p r i m a r y d a t a a n a l y s e s r e l a t e d t o t h e e x p e r i m e n t a l h y p o t h e s e s , i n o r d e r t o e s t a b - l i s h t h a t no s y s t e m a t i c d i f f e r e n c e s e x i s t e d as a r e s u l t o f b e i n g p l a c e d on the w a i t - l i s t o r n o t . A t t r e a t m e n t c o m p l e t i o n c l i e n t s were once a g a i n i n t e r - v iewed and d a t a t a k e n on a v a r i e t y o f measures . W a i t - l i s t c l i e n t s were measured on consumpt ion v a r i a b l e s a t the c o m p l e t i o n o f the w a i t - l i s t p e r i o d and t h e n p l a c e d i n t o t h e i r p r e - a s s i g n e d t r e a t m e n t . S i x months a f t e r the c o m p l e t i o n o f t r e a t m e n t , c l i e n t s were once a g a i n i n t e r v i e w e d and a s s e s s e d . 97 T h i s p r o c e d u r e i s r e p r e s e n t e d i n the F i g u r e 1 below. F i g u r e 1 H i s t o r i c a l D e s c r i p t i o n o f t h e O v e r a l l P r o c e d u r e (1) (2) (3) (4) (5) A l t e r n a t e P r e - T e s t Treatments P o s t - t e s t s F o l l o w - u p A s s i g n m e n t b e g i n a t s t a g - a t s t a g - f o r t r e a t e d gered t imes g e r e d t i m e s c l i e n t s C o n t a c t I n t e r v i e w Group Tx Tx ends A s s e s s beg ins a s s e s s C o n t a c t I n t e r v i e w I n d i v . Tx Tx ends , A s s e s s beg ins a s s e s s C o n t a c t I n t e r v i e w W a i t - l i s t E n d s , t h e n beg ins w a i t - l i s t was i n v i t e d i n t o t r e a t m e n t Tx - d e s i g n a t e s t rea tment 98 M a t e r i a l s The Treatment Program The group and i n d i v i d u a l t r e a t m e n t i n t e r v e n t i o n s u t i l i z e d a p a r a l l e l t r e a t m e n t manual . That i s , e v e r y e f f o r t was made t o ensure t h a t t h e two t r e a t m e n t s were as s i m i l a r as p o s s i b l e so t h a t t h e c o n t e n t o f t rea tment would not become an u n c o n t r o l l e d v a r i a b l e . In accordance w i t h t h i s c o n c e r n t h e t i m i n g and t h e t ime a l l o t t e d t o each o f t h e s e v e n t e e n t r e a t m e n t i n t e r v e n t i o n s was f i x e d i n t h e program d e s i g n . 'In a d d i t i o n , a h i g h l y s p e c i f i c t r ea tment manual was d e v e l o p e d t o c o n t r o l t h e c o n t e n t o f the i n t e r v e n t i o n s . However, t h e r e were i n e v i t a b l y some trea tment e f f e c t s which c o u l d not be so c o n t r o l l e d . These were c o n s i d e r e d minor i n l i g h t o f the above c o n t r o l s , a l t h o u g h t h i s was n o t measured, b u t a r e c o n s i d e r e d here f o r c o m p l e t e n e s s . F o r example, i n the i n t e r v e n t i o n c a l l e d "the f u n c t i o n a l a n a l y s i s o f d r i n k i n g " the c l i e n t s a r e asked t o a n a l y z e t h e i r d r i n k i n g e p i s o d e s and the f u n c t i o n s o f t h e s e . I n t h e group s e t t i n g l e s s t i m e was a v a i l a b l e f o r each t o d e s c r i b e h i s o r h e r f u n c t i o n a l a n a l y s i s . However, on the p o s i t i v e s i d e the 99 a n a l y s e s o f the o t h e r group members were a v a i l a b l e t o them. I n p a r t , t h i s f i t s w i t h one o f the proposed c u r a t i v e f a c t o r s o f groups i n p a r t i c u l a r , t h a t o f v i c a r i o u s l e a r n i n g and m o d e l i n g o r l e a r n i n g by the e x p e r i e n c e s o f o t h e r s . Thus t h i s i n t e r v e n t i o n was d i f f e r e n t i n a group s e t t i n g i n t h a t i t d e c r e a s e d the t ime a v a i l a b l e f o r each member and i n - c r e a s e d t h e t o t a l i n f o r m a t i o n a v a i l a b l e t o the c l i e n t i n c o m p a r i s o n t o the i n d i v i d u a l t r e a t m e n t . S i m i l a r d i f f e r e n c e s between t h e group and i n d i v i d u a l formats e x i s t e d w i t h t h e r e m a i n i n g i n t e r v e n t i o n s . The c u r r e n t s t u d y took p l a c e a t the V a n c o u v e r , B r i t i s h C o l u m b i a H e a l t h Department as an implementa t ion o f t h e SKILLS Program, which had been deve loped t o a s s i s t e a r l y - d i - agnosed prob lem d r i n k e r s i n r e d u c i n g t h e i r a l c o h o l consump- t i o n . The program was deve loped by D r . Lynne A l d e n and had been the s u b j e c t o f p r e v i o u s r e s e a r c h (Alden 1980, 1983) . However, the c o n t e n t o f the c u r r e n t t rea tment program was d e v e l o p e d s p e c i f i c a l l y f o r t h i s s t u d y . The t r e a t m e n t was a h i g h l y s t r u c t u r e d t r e a t m e n t program l a s t i n g f o r e i g h t weekly meet ings o f o n e - a n d - o n e - q u a r t e r h o u r s e a c h , p l u s one t o two hours homework p e r week. The c o n t e n t was e x t e n s i v e and i n v o l v e d seventeen i n t e r v e n t i o n s drawn from the works o f A l d e n (1980, 1983), M i l l e r & Munoz 100 (1982) , M a r l a t t & Gordon (1980), A d d i c t i o n R e s e a r c h F o u n d a - t i o n o f O n t a r i o (1982), J a n i s & Mann (1977), H e a t h e r & R o b e r t s o n (1982), S a n c h e z - C r a i g (1982), D ' Z u r i l l a & G o l d f r i e d (1973), McKay e t a l . (1981), and o t h e r s . Due t o t h e l e v e l o f s t r u c t u r i n g and the amount o f m a t e r i a l i t was p r o p o s e d t h a t the t h e r a p i s t g e n e r a t e d c o n t e n t would be c o n t r o l l e d and e s s e n t i a l l y s i m i l a r a c r o s s t r e a t m e n t c o n d i - t i o n s . That i s , t h a t c o n t e n t would be b a s i c a l l y s i m i l a r i n each o f group and i n d i v i d u a l f o r m a t s . T h i s was done as an e f f o r t t o reduce t h e r a p i s t and c o n t e n t e f f e c t . The c u r r e n t t rea tment program f o l l o w e d a s o c i a l - l e a r n i n g p e r s p e c t i v e o f human f u n c t i o n i n g and change common t o most o f the p r e v i o u s l y rev iewed t r e a t m e n t s a n d , i n f a c t , u t i l i z e d i n t e r v e n t i o n s from many o f t h e s e p r e v i o u s programs . S o c i a l - l e a r n i n g t h e o r y sugges t s t h a t b e h a v i o r r e s u l t s form i n t r a p e r s o n a l and i n t e r p e r s o n a l r e i n f o r c e r s and t h a t change r e q u i r e s a l t e r a t i o n s i n the a r r a y o f c o n t i n g e n c i e s which m a i n t a i n a prob lem b e h a v i o r . A c c o r d i n g l y , i n t e r v e n t i o n s e i t h e r p r o v i d e d b e h a v i o r a l s k i l l components which would s e r v e t o a l t e r d r i n k i n g behav- i o r and t o e n a b l e the c l i e n t s t o e x p e r i e n c e s u c c e s s a t d o i n g s o , o r were d e s i g n e d t o a l t e r the c o g n i t i o n s o f t h e c l i e n t i n r e l a t i o n t o t h e problem b e h a v i o r . C l i e n t s a t t e n d e d 101 t r e a t m e n t as t h e r e s u l t o f a d e c i s i o n t o a l t e r t h e i r d r i n k - i n g b e h a v i o r . T h i s d e c i s i o n was u s u a l l y c r i s i s - d r i v e n w i t h l i t t l e i n - d e p t h c o n s i d e r a t i o n o f t h e impact o f the d e c i s i o n i n terms o f the many c o s t s and b e n e f i t s t h a t would emerge i n t h e i r ongo ing l i f e s t y l e s . The s o c i a l - l e a r n i n g p e r s p e c t i v e sugges t s t h a t , u n l e s s the c o n t i n g e n c i e s r e l a t e d t o t h e s e c o s t s and b e n e f i t s o f change are a l t e r e d t o be c o n s i s t e n t w i t h the changes , the problem b e h a v i o r w i l l l i k e l y re -emerge o v e r t i m e . C l i e n t s i n the group c o n d i t i o n s a t around a l a r g e t a b l e , f a c i n g and i n t e r a c t i n g w i t h one a n o t h e r . The t h e r a - p i s t s a t a t one s i d e f r e q u e n t l y u s i n g a b l a c k - b o a r d . A l l i n t e r a c t i o n s o c c u r r e d w i t h i n the group c o n t e x t such as r e p o r t i n g d r i n k i n g amounts, p r o g r e s s c h a r t i n g , r e p o r t i n g t e c h n i q u e s used and e x p e r i e n c e s w i t h t h e s e , g i v i n g and r e c e i v i n g a d v i s e and feedback t o o t h e r group members, p e r s o n a l p e r c e p t i o n s and i n s i g h t s , f r u s t r a t i o n s and f a i l - u r e s . The purpose was t o ensure t h a t group i n t e r a c t i o n was t a k i n g p l a c e t o a l l o w f o r o p t i m a l c o n d i t i o n s f o r group p r o c e s s o r group i n f l u e n c e to d e v e l o p . 102 F i g u r e 2 I n t e r v e n t i o n s U t i l i z e d and T i m i n g o f T h e i r Use Weeks u s e d (1) M o n i t o r i n g and G r a p h i n g (2) A u t o b i o g r a p h y (3) A l c o h o l Problem I n f o r m a t i o n (4) D e c i s i o n a l Ba lance Sheet (5) Chang ing D r i n k i n g S t y l e 1 (6) S e t t i n g t h e Weekly G o a l (7) F u n c t i o n a l A n a l y s i s o f D r i n k i n g B e h a v i o r (8) R a t i o n a l i z a t i o n s (9) R e l a x a t i o n (10) Impulse C o n t r o l (11) Chang ing D r i n k i n g S t y l e 2 (12) Problem S o l v i n g (13) Thought C a t c h i n g (14) A p p a r e n t l y I r r e l e v a n t D e c i s i o n s and A b s t i n e n c e V i o l a t i o n E f f e c t (15) S e t t i n g L i m i t s f o r Y o u r s e l f (16) Inform O t h e r s o f a Commitment t o Change (17) L i f e s t y l e and Unmet Needs * * * * * * * * * 103 The t r e a t m e n t package was d e s i g n e d s p e c i f i c a l l y f o r the c u r r e n t s t u d y and drew on p r e v i o u s r e s e a r c h e r s ' e f f o r t s i n t h e a r e a s o f r educed a l c o h o l consumpt ion weight c o n t r o l and smoking c e s s a t i o n . A b r i e f d e s c r i p t i o n o f these i n d i v i d u a l t r e a t m e n t components f o l l o w s . S e v e r a l i n t e r v e n t i o n s were u t i l i z e d o r rev i ewed a t each m e e t i n g . They a r e p r e s e n t e d h e r e i n t h e o r d e r o f appearance i n t h e t rea tment p r o g r a m . The o r d e r o f p r e s e n t a t i o n i s a l s o summarized i n F i g u r e 2. 1) M o n i t o r i n g and G r a p h i n g T h i s s e c t i o n was based on work by M i l l e r & Munoz (1982) , A l d e n (1983), and o t h e r s . C l i e n t s were t a u g h t how t o m o n i t o r and q u a n t i f y t h e i r consuming b e h a v i o r . The p u r p o s e s o f t h i s a r e s e v e r a l . F i r s t l y i t p r o v i d e d more a c c u r a t e s e l f - r e p o r t d a t a , s e c o n d l y i t p r o v i d e d q u a n t i t a t i v e f i g u r e s which s e r v e d as a b a s e l i n e and , l a t e r , as p r o g r e s s m a r k e r s , and t h i r d l y i t h e l p e d the c l i e n t s t o become more aware o f t h e i r own d r i n k i n g p a t t e r n s and s e v e r i t y (See Append ix E) . M o n i t o r i n g and g r a p h i n g i s w e l l - d e s c r i b e d i n M i l l e r and Munoz (1982) . The r a t i o n a l e and method f o r t h i s 104 p r o c e d u r e was d e s c r i b e d i n d e t a i l so t h a t the c l i e n t c o u l d a c c u r a t e l y m o n i t o r consumpt ion , c o n v e r t t h i s t o S t a n d a r d D r i n k U n i t s , and graph weekly and peak day a l c o h o l consumption over the c o u r s e o f t r e a t m e n t . D e s c r i p t i o n , d e m o n s t r a t i o n , and a s s i s t a n c e w i t h t h i s p r o c e d u r e was r e p e a t e d o v e r a t l e a s t t h e f i r s t t h r e e weeks o f t r e a t m e n t and g r a p h i n g r e s u l t s were d i s c u s s e d weekly u n t i l the end o f t r e a t m e n t . A u t o b i o g r a p h y T h i s s e c t i o n was adopted from M a r l a t t & Gordon (1980), and Gawain (1979) . C l i e n t s a r e asked t o f i r s t d e s c r i b e themse lves as prob lem d r i n k e r s and t o d e s c r i b e what t h i s image meant t o them. The purpose was t o e x p l o r e s e l f - d e f e a t i n g n e g a t i v e v i s u a l i z a t i o n s o f t h e s e l f . C l i e n t s were then asked t o d e s c r i b e themse lves as they i n t e n d e d t o be a f t e r achievement o f t h e i r g o a l - c o n t r o l l e d and r e d u c e d d r i n k e r s . T h i s p o s i t i v e v i s u a l i z a t i o n was i n t e n d e d t o a i d i n t h e development o f a p o s i t i v e s e l f c o n c e p t and t o a s s i s t the c l i e n t i n making h i s o r h e r g o a l more r e a l i s t i c , more v i v i d , and t h u s more a t t a i n - a b l e , and a l s o i n v o l v e d becoming more e m o t i o n a l l y committed t o the g o a l o f b e h a v i o r s e l f - c o n t r o l and 105 reduced a l c o h o l consumpt ion . T h i s i s r e l a t e d t o d e c i s i o n - m a k i n g i n e x p l o r i n g a l t e r n a t i v e s . A u t o b i o g r a p h y was d e s c r i b e d and a s s i g n e d t o be c a r r i e d out a t home as a w r i t t e n ass ignment . The e x p e r i e n c e o f d o i n g the e x e r c i s e was d i s c u s s e d a t the f o l l o w i n g s e s s i o n i n o r d e r t o enhance the v i v i d n e s s o f b o t h t h e problem d r i n k e r and the c o n t r o l l e d d r i n k e r v i s u a l i z a - t i o n s and t o e x p l o r e any d i s c o v e r i e s o r prob lems e n c o u n t e r e d . 3) A l c o h o l Problem I n f o r m a t i o n T h i s m a t e r i a l was taken from M i l l e r & Munoz (1982) , & A d d i c t i o n R e s e a r c h F o u n d a t i o n (1982). T h i s s e c t i o n p r o v i d e d i n f o r m a t i o n on t h e r e a l i t y o f the g o a l o f prob lem d r i n k i n g and a l s o the h e a l t h r i s k o f c o n t i n u e d h i g h consumpt ion . A l c o h o l problem i n f o r m a t i o n c o n s i s t e d o f some i n f o r m a - t i o n from M i l l e r and Munoz (1982) (p.145-151) and an A d d i c t i o n R e s e a r c h F o u n d a t i o n V R i s k - O - G r a p h " w h i c h p i c t o r i a l l y p r e s e n t e d the comparat ive h e a l t h r i s k s o f low, medium, and h i g h a l c o h o l consumpt ion . T h i s i n f o r m a t i o n was p r e s e n t e d and d i s c u s s e d and c l i e n t s were a s s i g n e d t o r e a d the m a t e r i a l i n d e t a i l a t home. 106 D e c i s i o n a l B a l a n c e Sheet T h i s p a r t was adapted from J a n i s & Mann (1977) . The d e c i s i o n a l b a l a n c e sheet was i n t e n d e d t o a s s i s t t h e c l i e n t s t o r e - p r o c e s s the sometimes h a s t y d e c i s i o n t o reduce d r i n k i n g and t o r e a l i s t i c a l l y e x p l o r e t h e f a c t o r s t h a t may appea l t o them about a r e t u r n t o h i g h e r consumpt ion . The D e c i s i o n a l Balance Sheet i s d e s c r i b e d and p r e s e n t e d i n d e t a i l i n J a n i s and Mann (1977) . The t a s k was i n t r o d u c e d as an o p p o r t u n i t y t o r e c o n s i d e r t h e o f t e n - h a s t y d e c i s i o n t o reduce a l c o h o l consumpt ion w i t h d e t a i l e d c o n s i d e r a t i o n o f t h e c o s t s and b e n e f i t s i n v o l v e d i n d e c r e a s i n g consumpt ion . The t a s k was a s s i g n e d as homework a f t e r d i s c u s s i o n o f t h e t a s k and methodology , and the r e s u l t s were d i s c u s s e d d u r i n g t h e f o l l o w i n g s e s s i o n . Changing D r i n k i n g S t y l e I Adapted form M i l l e r & Munoz (1982) , H e a t h e r & R o b e r t s o n (1982) , and from v a r i o u s c l i e n t s and s t a f f . T h i s s e c t i o n p r o v i d e d n i n e t e e n s t r a t e g i e s f o r r e d u c i n g d r i n k consumpt ion a t a v e r y p r a c t i c a l l e v e l . C l i e n t s were asked t o e x p l o r e two o r more o f t h e i r c h o o s i n g . 107 Changing D r i n k i n g S t y l e 1 i s a l i s t o f d r i n k r e d u c t i o n t e c h n i q u e s . The l i s t was i n t r o d u c e d as a v a r i e t y o f s i m p l e , v a r i e d , and p o w e r f u l t e c h n i q u e s from which c l i e n t s a r e asked t o s e l e c t and t r y some. The methods were b r i e f l y d i s c u s s e d and i n f o r m a t i o n was e l i c i t e d as t o c l i e n t ' s p r e v i o u s e x p e r i e n c e s o f s u c c e s s o r f a i l u r e w i t h t h e t e c h n i q u e s . E x p e r i m e n t a t i o n was t h e n a s s i g n e d as homework and succes se s and problems d i s c u s s e d the f o l l o w i n g week. S e t t i n g t h e Weekly G o a l Adapted from b a s i c b e h a v i o r m o d i f i c a t i o n p r i n c i p l e s such as D i R i s i & Butz (1975), T h a r p & W e t z e l (1969) . From t h e second week onward c l i e n t s were asked t o commit themse lves t o a weekly a l c o h o l consumpt ion g o a l which was t w e n t y - f i v e t o t h i r t y p e r c e n t l e s s t h a n t h e i r p r i o r week's consumpt ion , o r a t t h e i r end g o a l . S e t t i n g t h e weekly g o a l b e g i n s a t t h e second week onward when c l i e n t s were asked t o s e l e c t an a t t a i n a b l e weekly d r i n k i n g t a r g e t f o r the f o l l o w i n g week. They were a s k e d t o d i s c u s s methods they p l a n n e d t o use i n o r d e r t o a c h i e v e the weekly g o a l . The f o l l o w i n g week the s u c c e s s o r f a i l u r e o f g o a l a t t a i n m e n t was d i s c u s s e d 108 a l o n g w i t h o t h e r methods which might p r o v e h e l p f u l . T h i s d i s c u s s i o n and g o a l - s e t t i n g was r e p e a t e d week ly . 7) F u n c t i o n a l A n a l y s i s o f D r i n k i n g B e h a v i o r T h i s was adapted from S a n c h e z - C r a i g (1982) . T h i s s e c t i o n r e t u r n e d t o d e c i s i o n making and e x p l o r e d f u r t h e r t h e a d a p t i v e i n t e n t o r h o p e d - f o r outcome i n c h o o s i n g t o o v e r d r i n k , t h e subsequent d i f f i c u l t i e s i n a c h i e v i n g t h e s e i n t e n d e d g o a l s a f t e r h a v i n g o v e r - consumed, and the e v e n t s i n which d r i n k i n g was r e d u c e d and g o a l a t t a i n m e n t was s u c c e s s f u l l y a c h i e v e d . F u n c t i o n a l A n a l y s i s o f D r i n k i n g has been d e s c r i b e d i n d e t a i l by S a n c h e z - C r a i g (1982) . T h i s was i n t r o d u c e d as an e x p l o r a t i o n o f t h e p e r s o n a l m o t i v a t i o n s f o r d r i n k i n g and t h e s u c c e s s o r f a i l u r e o f r e s p o n d i n g t o t h e s e m o t i v a t i o n s t h r o u g h o v e r - d r i n k i n g and t h r o u g h c o n t r o l - l i n g consumpt ion . A f t e r i n t r o d u c t i o n t h i s was a s s i g n e d as homework and the r e s u l t s d i s c u s s e d d u r i n g the f o l l o w i n g s e s s i o n . 8) R a t i o n a l i z a t i o n s Adapted from J a n i s & Mann (1977) . T h i s s e c t i o n r e t u r n e d t o d e c i s i o n making as w e l l and e x p l o r e s the s e l f - d e s t r u c t i v e n a t u r e o f 109 r a t i o n a l i z a t i o n s which are used i n o r d e r t o c o n t i n u e on a known p r o b l e m a t i c p a t h such as o v e r d r i n k i n g . The i n t e n t was t o c l e a r l y p o r t r a y the most common r a t i o n a l - i z a t i o n s , t o i l l u s t r a t e t h e i r i l l u s o r y q u a l i t i e s and t o r e d u c e t h e i r i m p a c t . R a t i o n a l i z a t i o n s has been d e r i v e d p r i m a r i l y from J a n i s and Mann (1977) and i s d e t a i l e d t h e r e i n . R a t i o n a l i z a - t i o n s were i n t r o d u c e d as myths r e p e a t e d o f f - h a n d e d l y t o s u p p o r t o l d d e c i s i o n s and a v o i d the t u r m o i l o f becoming r e - e n g a g e d i n a d e c i s i o n - m a k i n g p r o c e s s . J a n i s and Mann's l i s t o f r a t i o n a l i z a t i o n s around smoking was d i s c u s s e d and t h e n r a t i o n a l i z a t i o n s around d r i n k i n g were e l i c i t e d . A l i s t o f t h e s e was then o f f e r e d and added t o i f p o s s i b l e by each c l i e n t . C l i e n t s were a s s i g n e d t o d i s c o v e r how they used r a t i o n a l i z a t i o n s and t h i s was d i s c u s s e d i n the f o l l o w i n g s e s s i o n . R e l a x a t i o n A d a p t e d from commonly used r e l a x a t i o n / h y p n o t i c i n d u c - t i o n t e c h n i q u e s . C l i e n t s l e a r n e d and p r a c t i c e d a b r i e f r e l a x a t i o n p r o c e d u r e which c o u l d be used i n any s i t u a t i o n f o r any l e n g t h o f t i m e . The purpose o f the t e c h n i q u e was t o a s s i s t the c l i e n t i n r e d u c i n g t e n s i o n a t g i v e n moments 110 so t h a t h e / s h e would r e c a l l and be a b l e t o use h i s / h e r g o a l and d r i n k i n g p l a n . R e l a x a t i o n i s a s t a n d a r d r e l a x a t i o n sequence adapted so t h a t i t can be used i n any s i t u a t o n . T h i s a d a p t i o n was d i s c u s s e d as r e l e v a n t t o the t a s k o f c o n t r o l l e d d r i n k - i n g . R e l a x a t i o n was demonstrated i n a c h a i r w i t h c l o s e d eyes on two s e s s i o n s and d i s c u s s e d and a s s i g n e d t o be used between s e s s i o n s . W i t h c l o s e d eyes c l i e n t s a r e t a u g h t t o a s s o c i a t e the r e l a x a t i o n o f t h e i r musc les upon b r e a t h i n g out w i t h a f e e l i n g o f ' b e i n g r e l a x e d . 7 They were then t a u g h t t o a s s o c i a t e a p a s s i v e v o l i t i o n a l o r p e r m i s s i v e sense o f r e l a x a t i o n w i t h the word ' r e l a x ' and ,the muscu lar r e l a x a t i o n o f l e t t i n g b r e a t h e x h a l e . The e x e r c i s e was a s s i g n e d and d i s c u s s e d i n t h e f o l l o w - i n g s e s s i o n . 10) Impulse c o n t r o l A d a p t e d from D ' Z u r i l l a & G o l d f r i e d (1973) , and M a r l a t t & Gordon (1980). T h i s s e c t i o n gave a b r i e f p r o c e d u r e and d e m o n s t r a t i o n o f an impul se c o n t r o l t e c h n i q u e s i m i l a r t o c o v e r t s e n s i t i z a t i o n and was d e s i g n e d t o reduce d r i n k i n g urges when t h e y d e v e l o p . I l l The impul se c o n t r o l sequence has been a d a p t e d from s e v e r a l w r i t e r s . B r i e f l y , impulses were i n t r o d u c e d and d i s c u s s e d as a f f e c t i v e p r e s s u r e s t h a t t e n d t o s h o r t - c i r c u i t d e c i s i o n - m a k i n g , and i t was s t a t e d t h a t problem i m p u l s e s c o u l d u s u a l l y be i d e n t i f i e d f o r each p e r s o n and p r e p a r e d f o r . The problem impulse o f d r i n k i n g was d i s c u s s e d and a means o f e s t i m a t i n g the s e v e r i t y o f t h i s impul se was chosen . Then two t y p e s o f c o g n i t i v e i n t e r v e n t i o n s were chosen and d e v e l o p e d : one a l i s t o f r e a s o n s f o r no t c a r r y i n g out t h e prob lem b e h a v i o r , t h e second an i m a g i n a l scene o f consequences o f t h e prob lem b e h a v i o r . I n two s e s s i o n s and a s s i g n e d i n betewen c l i e n t s were asked t o measure the i m p u l s e , use e i t h e r o r b o t h o f t h e l i s t and the image f o r t e n s e c o n d s , r e -measure t h e i m p u l s e , and t h e n e i t h e r r e - u s e t h e i n t e r v e n t i o n o r e x i t , r e v i e w i n g p o s s i b l e prob lems and changes , and r e w a r d i n g themse lves c o g n i t i v e l y . Chang ing D r i n k i n g S t y l e I I Adapted from M i l l e r & Munoz (1982), and H e a t h e r & R o b e r t s o n (1982) . T h i s s e c t i o n gave more g e n e r a l s t r a t e g i e s t h a n Changing D r i n k i n g S t y l e I and was d e s i g n e d t o a s s i s t t h e c l i e n t i n u n d e r s t a n d i n g the ways i n which e n v i r o n m e n t , p e o p l e , and o t h e r f a c t o r s i n f l u e n c e d h i s d r i n k i n g c o m p u l s i o n s 112 and t o h e l p h i m / h e r become aware o f methods f o r c o n - t r o l l i n g t h i s i n f l u e n c e . C l i e n t s committed t o u t i l i z e these s t r a t e g i e s and r e p o r t b a c k . Changing D r i n k i n g S t y l e I I i s adapted from M i l l e r and Munoz (1982) and Rob inson and H e a t h e r (1982) . T h i s was i n t r o d u c e d as an e x p l o r a t i o n o f t h e c i r c u m s t a n c e s o f prob lem d r i n k i n g : a n t e c e d e n t s , l o c a t i o n , p e r s o n s , t i m e s , emot ions , and o t h e r markers a s s o c i a t e d w i t h prob lem d r i n k i n g These were i n t r o d u c e d i n d e t a i l and the c l i e n t was a s s i g n e d t o e x p l o r e t h e s e i n t h e coming week, from e x p e r i e n c e o r memory. These were d i s c u s s e d d u r i n g the f o l l o w i n g s e s s i o n . 12) P r o b l e m - S o l v i n g Adapted from M a r l a t t & Gordon (1980) , D ' Z u r i l l a & G o l d f r i e d (1973), S a n c h e z - C r a i g (1982), McKay e t a l . (1981) , and J a n i s & Mann (1977) . T h i s s e c t i o n d e v e l o p e d g e n e r a l p r o b l e m - s o l v i n g s t r a t e - g i e s . I t i n c l u d e d t h e f o l l o w i n g : r easons c i t e d by f a i l e d c l i e n t s f o r t h e i r f a i l u r e t o m a i n t a i n s u c c e s s , p r e v i o u s f a i l u r e r a t e s , and g e n e r a l p r o b l e m - s o l v i n g methodology i n c l u d i n g b l o c k e d d e c i s i o n s and t h e a p p l i - c a t i o n o f p r o b l e m - s o l v i n g t o i n t e r p e r s o n a l r e l a t i o n - s h i p s and n e g a t i v e s e l f images . The purpose was t o 113 p r o v i d e a t o o l f o r use w i t h d r i n k i n g and o t h e r p r o b - l ems . Problem s o l v i n g was adapted d i r e c t l y from S a n c h e z - C r a i g (1982) and a d e t a i l e d d i s c u s s i o n may be found t h e r e i n . Problem s o l v i n g s t a g e s were d e s c r i b e d and d i s c u s s e d i n g e n e r a l , and then prob lem s o l v i n g o f i n t e r p e r s o n a l problems and n e g a t i v e emot ions were d i s c u s s e d . R e f e r - ence i s made t o the f a i l u r e o f most prob lem d r i n k e r s i n a s h o r t t i m e due p r i m a r i l y t o t h e s e two prob lem a r e a s . B l o c k a g e s t o problem s o l v i n g were a d d r e s s e d as u n r e - s o l v e d i n t e r n a l c o n f l i c t s and methods o f r e s o l v i n g t h e s e were d i s c u s s e d and demonstra ted b r i e f l y . The a c t i v i t y was a s s i g n e d and d i s c u s s e d a t t h e f o l l o w i n g s e s s i o n . Thought C a t c h i n g Adapted from McKay e t a l . (1981) , and Meichenbaum & Genest (1980) , and c l i n i c a l e x p e r i e n c e . T h i s t e c h n i q u e was d e s i g n e d t o s e n s i t i z e t h e c l i e n t t o m i n i m a l awareness s e l f - d e f e a t i n g t h i n k i n g and t o t h e n r e s p o n d by u s i n g a method o f c o u n t e r a c t i n g t h e impact o f t h i s t h i n k i n g . 114 Thought C a t c h i n g was i n t r o d u c e d as impul se c o n t r o l d i r e c t e d toward e a r l y - e m e r g i n g impul se s t o o v e r d r i n k r a t h e r t h a n f u l l - b l o w n c r a v i n g s . C l i e n t s were t a u g h t by d i s c u s s i o n and d e m o n s t r a t i o n how t o d e t e c t and c o n t r o l t h e s e emerging i m p u l s e s and t o t h e n use impul se c o n t r o l methods t o reduce them. T h i s was e x p l o r e d a t one s e s s i o n , t h e n a s s i g n e d d u r i n g the f o l l o w i n g week and d i s c u s s e d i n the f o l l o w i n g s e s s i o n . 14) A p p a r e n t l y I r r e l e v a n t D e c i s i o n s and A b s t i n e n c e V i o l a t i o n E f f e c t Adapted from M a r l a t t & Gordon (1980) . These t e c h n i q u e s a d d r e s s e d two e x p e r i e n c e s which a r e commonly a s s o c i a t e d w i t h o v e r c o n s u m p t i o n . The f i r s t i s d e c i s i o n s made which a r e a p p a r e n t l y u n r e l a t e d t o d r i n k i n g but t e n d t o l e a d t o h i g h e r r i s k s i t u a t i o n s , and the a b s t i n e n c e v i o l a t i o n e f f e c t i s t h e c h o i c e t o f e e l f a i l u r e and choose abandonment o f g o a l s when s u c c e s s i s no t met, and t o use t h i s t o p e r m i t an e p i s o d e o f o v e r d r i n k i n g . The purpose was t o s e n s i t i z e the c l i e n t s t o t h e s e p r o c e s s e s i n o r d e r t o c o n t r o l t h e i r i m p a c t s . A p p a r e n t l y i r r e l e v a n t d e c i s i o n s and a b s t i n e n c e v i o l a - t i o n e f f e c t a r e b o t h d i s c u s s e d i n d e t a i l i n M a r r l a t t 115 and Gordon (1980). The concept s were i n t r o d u c e d by c l i n i c a l examples and an e x p l o r a t i o n o f the e f f e c t s o f t h e s e i n t h e l i f e s t y l e s o f the c l i e n t s ensued . P l a n - n i n g f o r t h e s e f o l l o w e d w i t h s p e c i f i c b e h a v i o r s e l f - c o n t r o l methods b e i n g d e v e l o p e d . D e t e c t i o n o f the i n f l u e n c e o f e i t h e r o r b o t h o f these c o n c e p t s w i t h a p p r o p r i a t e i n t e r v e n t i o n s was then a s s i g n e d and d i s - c u s s e d d u r i n g the f o l l o w i n g s e s s i o n . 15) S e t t i n g L i m i t s f o r Y o u r s e l f Adapted from M i l l e r & Munoz (1982), & A l d e n (1980) . T h i s s e c t i o n i n c l u d e d a c o n t r a c t w i t h o n e s e l f around a l c o h o l consumpt ion . The purpose was t o a g a i n make more e x p l i c i t and committed the d e c i s i o n t o reduce a l c o h o l consumpt ion . S e t t i n g l i m i t s f o r y o u r s e l f i s d i s c u s s e d i n d e t a i l i n M i l l e r and Munoz (1982). C l i e n t s were asked t o e x p l o r e and commit themse lves t o a l c o h o l consumpt ion l i m i t s and t o c a l c u l a t e exac t numbers o f these by c o n s i d e r i n g body w e i g h t , a l c o h o l c o n c e n t r a t i o n i n a b e v e r a g e , and a l c o h o l l e v e l i n the b l o o d . D i s c u s s i o n , c a l c u l a t i o n and commitment took p l a c e i n one s e s s i o n and were a s s i g n e d . D i s c u s s i o n o f problems and d i s c o v e r i e s took p l a c e i n the f o l l o w i n g s e s s i o n . 116 16) Inform O t h e r s o f a Commitment t o Change T h i s was adapted from r e s e a r c h by F e s t i n g e r (1959) , Bern (1967), Rokeach (1971). T h i s s e c t i o n i n v o l v e d a f u r t h e r s t ep i n d e c i s i o n making , p u b l i c l y s t a t i n g t h a t a change has o c c u r r e d o r i s o c c u r r i n g . The purpose was t o enhance commitment t o change. Inform o t h e r s o f a Commitment t o Change was i n t r o d u c e d as a method o f s u p p o r t i n g d e c i s i o n s t o change t h r o u g h more p u b l i c s ta tements o f t h e s e commitments. C l i e n t s were asked t o d i s c u s s t h i s e x e r c i s e and t h e n choose someone i n t h e i r environment t o i n f o r m about t h e i r changed a l c o h o l consumption p a t t e r n s . They t h e n were a s s i g n e d t o i n f o r m t h i s p e r s o n and r e p o r t t h e r e s u l t s back t o t h e group the f o l l o w i n g week f o r f u r t h e r d i s c u s s i o n . 17) L i f e s t y l e and Unmet Needs Adapted from G l a s s e r (1965) and c l i n i c a l e x p e r i e n c e . The p u r p o s e s o f t h i s s e c t i o n were t o h e l p c l i e n t s become aware o f t h e i r p e r s o n a l needs i n o r d e r t o d i s c o v e r whether o r not t h e s e were c u r r e n t l y met, t o u n d e r s t a n d t h e f u n c t i o n o f a l c o h o l as an a l t e r n a t i v e t o meet ing needs d i r e c t l y , and t o u n d e r s t a n d t h e f u n c t i o n 117 o f meet ing needs d i r e c t l y i n m a i n t a i n i n g lower a l c o h o l consumpt ion . L i f e s t y l e and Unmet Needs i n t r o d u c e d the c o n c e p t o f p e r s o n a l needs and the r e q u i r e m e n t t h a t t h e s e be met i n o r d e r t o f e e l complete and s a t i s f i e d . When t h e y a r e not met a p e r s o n w i l l f e e l f r u s t r a t e d , perhaps b i t t e r and h o p e l e s s . The p e r s o n may t r y t o a d d r e s s t h e need i n d i r e c t l y , through problem d r i n k i n g . C l i e n t s were asked t o d i s c u s s the ways i n which t h e y used a l c o h o l i n t h i s f a s h i o n i n the p a s t and how t h e i r p e r s o n a l needs were not met a t t h a t t i m e . They were t h e n asked about how e f f e c t i v e l y they were meet ing t h e i r needs a t t h e p r e s e n t , emphas i z ing the i m p e r a t i v e t o meet t h e i r needs t o m a i n t a i n c o n t r o l l e d d r i n k i n g and b r i n g i n g t o aware- ness the l e g a c y o f f e e l i n g s around needs not w e l l met. S c r e e n i n g Measures S e v e r a l measures were taken a t the o u t s e t . Some o f t h e s e ; a l c o h o l consumpt ion , L i f e S a t i s f a c t i o n Q u e s t i o n n a i r e , P r o f i l e o f Mood S t a t e s , and the Weissman S o c i a l Adjus tment S c a l e , were a l s o used as measures o f t r e a t m e n t e f f e c t and t h u s w i l l be d i s c u s s e d i n the next s e c t i o n , Dependent V a r i a b l e s . The r e s t were p r i m a r i l y demographic , i n c l u d e d t o 118 g i v e a more complete p i c t u r e o f the t y p e o f s u b j e c t s who t o o k p a r t i n t h i s s t u d y . Thus the f o l l o w i n g d a t a were c o l l e c t e d : gender , age, r e l a t i o n s h i p s t a t u s , employment s t a t u s , e d u c a t i o n l e v e l , h i s t o r y o f prob lem d r i n k i n g i n the f a m i l y o f o r i g i n , d u r a t i o n o f d r i n k i n g p r o b l e m , and s c o r e s on the M i c h i g a n A l c o h o l i s m S c r e e n i n g T e s t . The M i c h i g a n A l c o h o l i s m S c r e e n i n g T e s t (MAST) ( S e l z e r 1971) (See Appendix F) i s a f r e q u e n t l y used i n s t r u m e n t f o r t h e c a t e g o r i z a t i o n o f c l i e n t s w i t h r e g a r d t o s e v e r i t y o f a l c o h o l p r o b l e m s . The MAST has been u t i l i z e d i n p r e v i o u s c o n t r o l l e d d r i n k i n g s t u d i e s and found t o be a u s e f u l measure o f p r o b l e m s e v e r i t y . A s t u d y sample r e p o r t e d by S a n c h e z - C r a i g e t a l . (1984) had an average MAST s c o r e o f 1 8 . 6 . A s t u d y sample r e p o r t e d by M i l l e r and Baca (1983) which combined s u b j e c t s o f the M i l l e r T a y l o r & West (1980) s t u d y and the M i l l e r & T a y l o r (1980) s t u d y was found t o have an average MAST s c o r e o f 1 6 . 8 . The sample used by M i l l e r , G r i b s k o v & M o r t e l l (1981) had an average MAST s c o r e o f 17 .59 . M i l l e r , Pechacek and Hamburg (1981) s t u d i e d a sample w i t h an average MAST s c o r e o f 1 5 . 5 . 119 Dependent Measures Two p r i m a r y dependent v a r i a b l e s were i n c l u d e d , p l u s a number o f s e c o n d a r y and e x p l o r a t o r y dependent measures . These w i l l be d i s c u s s e d below. A l c o h o l Consumption The p r i m a r y dependent measures were chosen because they were c e n t r a l t o t h e g o a l s o f the t r e a t m e n t and t h e y a r e a common measure o f t r e a t m e n t outcome i n c o n t r o l l e d d r i n k i n g r e s e a r c h . These dependent measures were (1) weekly a l c o h o l consumpt ion and (2) peak day a l c o h o l c o n s u m p t i o n . The da ta was o b t a i n e d by s e l f - r e p o r t u s i n g s e l f - m o n i t o r i n g c a r d s c o l l e c t e d a t the b e g i n n i n g s o f the second and l a t e r s e s s i o n s o f t r e a t m e n t and f o l l o w - u p . The c a r d s were f i l l e d out d u r i n g a l l d r i n k i n g events (or immed ia t e ly a f t e r i f ano ther method was chosen f o r m o n i t o r i n g a t the t ime o f consump- t i o n ) . Weekly consumpt ion was measured i n S t a n d a r d D r i n k U n i t s ( S . D . U . ) ( M i l l e r & Munoz, 1982) , a method o f a s s e s s i n g a l c o h o l c o n t e n t independent o f s t r e n g t h o f d r i n k and volume. T h u s , f o r example , a b o t t l e o f 5% b e e r i s 1.2 S . D . U . , a 4 120 o z . g l a s s o f wine i s 1 S . D . U . , a 1 o z . g l a s s o f s p i r i t s i s .8 S . D . U . and so o n . Weekly consumption c o n s i s t s o f the t o t a l S t a n d a r d D r i n k U n i t s consumed o v e r seven d a y s . Peak consumpt ion c o n s i s t s o f the t o t a l S t a n d a r d D r i n k U n i t s consumed on the h e a v i e s t consuming day d u r i n g the p e r i o d i n which t h e weekly consumption f i g u r e s were b e i n g g a t h e r e d . S e l f - r e p o r t o f d r i n k i n g t h r o u g h s e l f - m o n i t o r i n g i s an e a s i l y t a u g h t p r o c e d u r e and i s g e n e r a l l y a c c e p t e d as r e l i - a b l e and v a l i d . Secondary dependent measures were chosen f o r f u r t h e r e x p l o r a t i o n o f t r e a t m e n t impact . These were: r e p o r t e d p r o b l e m s e v e r i t y , r e p o r t e d mood, and r e p o r t e d s o c i a l a d j u s t - ment. These a r e d i s c u s s e d below. L i f e S a t i s f a c t i o n Q u e s t i o n n a i r e R e p o r t e d prob lem s e v e r i t y was chosen i n o r d e r t o r e f l e c t changes on a v a r i e t y o f l i f e problems o t h e r t h a n consumpt ion o v e r the c o u r s e o f t r e a t m e n t . I t was p r o p o s e d t h a t t r e a t m e n t would a l s o impact t h e s e o t h e r areas as the c l i e n t e x p e r i e n c e d s u c c e s s a t r e d u c i n g consumpt ion , and as t h e c h e m i c a l e f f e c t o f the a l c o h o l i n t e r f e r e d l e s s i n p r o b l e m - s o l v i n g o r problem awareness . 121 A n o n - s t a n d a r d i z e d measure was i n use a t the Vancouver H e a l t h Department SKILLS Program and was adapted f o r t h i s purpose (Appendix G ) . The measure i s a b r i e f c h e c k - l i s t o f e i g h t problems t o be r a t e d on a f i v e p o i n t L i k e r t S c a l e r a n g i n g form "not a t a l l " t o " c o m p l e t e l y . " T h i s s c a l e , e n t i t l e d t h e " L i f e S a t i s f a c t i o n Q u e s t i o n n a i r e " i n c l u d e d the f o l l o w i n g i t e m s : i n t i m a t e r e l a t i o n s h i p s , j o b o r c a r e e r , a b i l i t y t o cope w i t h s t r e s s o r a n x i e t y , a b i l i t y t o cope w i t h d e p r e s s i o n , s o c i a l r e l a t i o n s h i p s o f s u p p o r t , s e l f - e s t e e m , a b i l i t y t o e x p r e s s anger , and a b i l i t y t o e x p r e s s f e e l i n g s . The measure i s s c o r e d by a d d i n g up t h e p o i n t s over t h e i t e m s . An i n t e r - i t e m c o r r e l a t i o n a l a n a l y s i s was c a r r i e d out on t h e q u e s t i o n n a i r e w i t h the sample u t i l i z e d f o r t h i s s t u d y a t i n t a k e , and an i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y c o e f f i c i e n t ( C r o n b a c h ' s A l p h a ) o f .84 was f o u n d , which was deemed adequate f o r r e s e a r c h p u r p o s e s . P r o f i l e o f Mood S t a t e s R e p o r t e d mood was a l s o expec ted t o be a l t e r e d by t r e a t m e n t p r o g r e s s , such t h a t e l e v a t e d mood was e x p e c t e d as s u c c e s s a t r e d u c i n g a l c o h o l consumpt ion was e x p e r i e n c e d and t h e c h e m i c a l d e p r e s s i n g e f f e c t o f a l c o h o l m i n i m i z e d . 122 The measure chosen t o a s s e s s mood was a s t a n d a r d i z e d p u b l i s h e d measure (McNair , L o r r , Droppleman, 1981) and has been used i n p r e v i o u s r e s e a r c h i n c o n t r o l l e d d r i n k i n g ( M i l l e r , 1978, M i l l e r , H e d r i c & T a y l o r , 1983, M i l l e r & B a c a , 1983) , and been found t o be r e s p o n s i v e t o t r e a t m e n t (See Append ix H ) . T h i s s e l f r e p o r t measure, t h e P r o f i l e o f Mood S t a t e s (POMS) c o n s i s t e d o f s i x t y - f i v e a d j e c t i v e s t o be e n d o r s e d on a L i k e r t - t y p e s c a l e r a n g i n g from "not a t a l l " , "a l i t t l e " , "moderate ly" , " q u i t e a b i t " , and "extremely" t o t h e q u e s t i o n "How have you been f e e l i n g d u r i n g t h e p a s t week i n c l u d i n g t o d a y ? " S i x a f f e c t i v e s t a t e s were a s s e s s e d : t e n s i o n - a n x i e - t y , d e p r e s s i o n - d e j e c t i o n , a n g e r - h o s t i l i t y , v i g o r , f a t i g u e - i n e r t i a , and c o n f u s i o n - b e w i l d e r m e n t . The s c a l e was s c o r e d t o e l i c i t a " T o t a l Mood D i s t u r b a n c e Score" which was "ob- t a i n e d by summing the s c o r e s (w i th v i g o r we ighted n e g a t i v e - l y ) on t h e s i x p r i m a r y mood f a c t o r s " ( p . 6 , M c N a i r e t a l . 1981) . Weissman S o c i a l Adjustment S c a l e R e p o r t e d s o c i a l adjus tment was a l s o e x p e c t e d t o be r e l a t e d t o t rea tment s u c c e s s f o r s i m i l a r r e a s o n s . T h a t i s , i t was expec ted t h a t g e n e r a l s o c i a l f u n c t i o n i n g would 123 i n c r e a s e w i t h t rea tment p r o g r e s s as a f u n c t i o n o f i n c r e a s e d c o n t r o l o f a l c o h o l consumpt ion . A number o f s o c i a l adjus tment s c a l e s were r e v i e w e d and t h e Weissman S c a l e was s e l e c t e d as t h e one b e s t s u i t e d t o t h e t r e a t m e n t p o p u l a t i o n , as most o t h e r s were d e v e l o p e d f o r c h r o n i c menta l p a t i e n t s . The S o c i a l Adjus tment S c a l e - s e l f R e p o r t was d e v e l o p e d by Weissman (1976) f o r use w i t h o u t p a - t i e n t d e p r e s s i v e s and has been used w i t h a v a r i e t y o f s u b j e c t groups and found t o have h i g h r e l i a b i l i t y . I t a s s e s s e s f u n c t i o n i n g i n the f o l l o w i n g a r e a s by s e l f - r e p o r t on a L i k e r t - t y p e S c a l e : Work o u t s i d e t h e home, work a t home, work as a s t u d e n t , s o c i a l and l e i s u r e t ime use , ex tended ' f a m i l y , m a r i t a l f u n c t i o n i n g , p a r e n t a l f u n c t i o n i n g , f a m i l y u n i t , and economic f u n c t i o n i n g . An o v e r a l l a d j u s t - ment s c o r e i s o b t a i n e d by d i v i d i n g t h e sum o f a l l i t e m s c o r e s by t h e number o f i tems a c t u a l l y used (See A p p e n d i x F) . Data were a n a l y z e d f i r s t t o o b t a i n a summary o f the demographic d a t a and t o p r o v i d e checks f o r a number o f i s s u e s r e q u i r e d t o enhance the v a l i d i t y o f t h e r e s u l t s . F o l l o w i n g t h i s , a n a l y s e s o f c o v a r i a n c e were c a r r i e d o u t , u t i l i z i n g c o n t r a s t s r e p r e s e n t i n g t h e r e s e a r c h h y p o t h e s i s . 124 CHAPTER 4 R e s u l t s T h i s c h a p t e r p r e s e n t s t h e r e s u l t s o f t h e s t u d y w i t h emphasis on the s t a t i s t i c a l t r e a t m e n t o f t h e d a t a . The c h a p t e r i s d i v i d e d i n t o two s e c t i o n s . The f i r s t s e c t i o n r e p o r t s t h e s t a t i s t i c a l a n a l y s e s o f t h e v a r i o u s subgroups used i n the s t u d y i n o r d e r t o e s t a b l i s h t h e e q u i v a l e n c y o f t h e compar i son g r o u p s . The second s e c t i o n r e p o r t s t h e s t a t i s t i c a l a n a l y s e s s p e c i f i c t o t h e t e s t i n g o f t h e hypotheses i n q u e s t i o n . S e c t i o n One: D e s c r i p t i v e S t a t i s t i c s In o r d e r t o a v o i d the m e t h o d o l o g i c a l prob lems c i t e d i n t h e major e a r l i e r s t u d i e s c i t e d i n t h e r e v i e w c h a p t e r , i t i s e s s e n t i a l t o c a r r y out s t a t i s t i c a l c o n t r a s t s w h i c h w i l l e s t a b l i s h e q u i v a l e n c y o f s u b j e c t groups i n t h e d i f f e r e n t c o n d i t i o n s . Thus i t i s n e c e s - s a r y t o e s t a b l i s h t h a t the t r e a t m e n t c o n d i t i o n s d i d no t 125 Table 1 Characterist ics of Cl ients i n Group and individual Treatment: Hypothesis 1 Socia l and Demccrraphic Variables Variable Group (n=16) Individual Age (years) M 38.31 SD 9.51 Education (years) M 13.94 SD 2.02 Duration of Problem (years) M 5.19 SD 2.86 Sex Males 50% Females - 50% •Relationship Couple 87.50% Single 12.50% Employment Employed 81.30% Unemployed 18.80% Family History Drinking Problem 56.30% No Drinking Problem 43.80% •Signif icant Other Present at pre & post-test 68.8% Not Present at both 31.30% 35.00 8.27 13.38 2.33 4.63 4.87 37.50% 62.5% 50% 50% 81.30% 18.80% 62.50% 37.50% 25.00% 75.0% *p<.05 126 d i f f e r s i g n i f i c a n t l y a t t h e p r e - t e s t p o s i t i o n . Demo- g r a p h i c d a t a i s a l s o p r e s e n t e d i n t h i s s e c t i o n f o r each h y p o t h e s i s s e p a r a t e l y and then f o r the e n t i r e s u b j e c t sample f o r the s t u d y . In t h i s s e c t i o n the d e s c r i p t i v e s u b j e c t i n f o r m a t i o n i s p r e s e n t e d . The i n f o r m a t i o n i s summarized i n T a b l e s 1 t o 4. T a b l e 1 r e f e r s t o t h e s u b j e c t p o o l u t i l i z e d i n the t e s t o f H y p o t h e s i s One ( H o i : Group format w i l l be more e f f e c t i v e than i n d i - v i d u a l f o r m a t ) . T h i s t a b l e summarizes t h e s o c i a l and demographic d a t a which were t h e n c o n t r a s t e d by t - t e s t f o r t h e r a t i o d a t a and by C h i - S q u a r e f o r the nominal d a t a t o t e s t f o r s i g n i f i c a n t d i f f e r e n c e s antecedent t o t h e exper iment between t h e s u b j e c t s i n t h e two t r e a t - ment c o n d i t i o n s . Of f o u r t e e n r e l e v a n t measures o n l y two were found t o be s i g n i f i c a n t l y d i f f e r e n t and these were l i k e l y r e l a t e d . The group c o n d i t i o n was found t o have s i g n i f - i c a n t l y more s u b j e c t s who were i n a r e l a t i o n s h i p , 87.5% as compared t o 50% i n the i n d i v i d u a l c o n d i t i o n . A l s o , t h e group c o n d i t i o n had s i g n i f i c a n t l y more s u b j e c t s who p r o v i d e d a s i g n i f i c a n t o t h e r a t p r e - t e s t and p o s t - t e s t , 68.8%, as compared t o 25% i n the i n d i v i d u a l 127 Table 2 Characterist ics of Clients i n Group and Individual Treatment: Hypothesis 1 Alcohol Consumption and Related Pre-test Measures Variable Group (n=16) Individual fn=16) Weekly Consumption at Screening Interview M 28.00 24.79 SD 10.56 11.67 Peak Consumption at Screening Interview M 9.50 9.07 SD 3.41 4.67 L i f e Satisfaction Problem Checklist M 26.88 26.50 SD 3.74 5.08 Prof i l e of'Mood States M 43.25 66.07 SD 44.28 56.65 Social Adjustment Scale M 1.88 1.93 SD .33 .60 Michigan Alcoholism Screening Test M 10.63 14.36 SD 6.30 12.25 128 c o n d i t i o n . A l l o t h e r d imens ions were n o n - s i g n i f i c a n t . I t was c o n c l u d e d t h a t on most o f the f o u r t e e n measured d i m e n s i o n s the two c o n d i t i o n s were e s s e n t i a l l y s i m i l a r and t h a t d i f f e r e n c e s a t p o s t - t r e a t m e n t c o u l d t h u s be a t t r i b u t e d t o event s o c c u r r i n g a f t e r the p r e - t e s t , such as the t r e a t m e n t f o r m a t s . T a b l e 2 summarizes t h e p r e - t e s t measure r e s u l t s (on the v a r i a b l e s l a t e r u t i l i z e d as dependent measures) o f the t r e a t m e n t c o n d i t i o n s used i n the t e s t o f t h e f i r s t h y p o t h e s i s . No s i g n i f i c a n t d i f f e r e n c e s emerged on any o f t h e f i v e p r e - t e s t measures , f u r t h e r s u p p o r t i n g t h e c o n c l u s i o n t h a t the s u b j e c t s i n t h e s e p a r a t e t r e a t m e n t c o n d i t i o n s a r e e s s e n t i a l l y s i m i l a r . T a b l e 3 r e f e r s t o the s u b j e c t p o o l u t i l i z e d i n H y p o t h e s i s two (H02: Treatment w i l l be more e f f e c t i v e t h a n no t r e a t m e n t ) . These d a t a were t h e n c o n t r a s t e d by t - t e s t and C h i - S q u a r e . On these c o n t r a s t s t h r e e mea- s u r e s o f t h e f o u r t e e n measures t a k e n were found t o be s i g n i f i c a n t l y d i f f e r e n t between t h e t r e a t e d c o n d i t i o n and the w a i t - l i s t c o n t r o l c o n d i t i o n a t p o s t - t e s t . These i n c l u d e t h e two enumerated above i n t h e s u b j e c t p o o l f o r the f i r s t h y p o t h e s i s , which i s u n d e r s t a n d a b l e 129 s i n c e t h e two s u b j e c t p o o l s l a r g e l y o v e r l a p p e d and t h e numbers g o i n g from the w a i t - l i s t t o the t r e a t m e n t c o n d i t i o n s were h e a v i l y dominated by those who went t o t h e i n d i v i d u a l c o n d i t i o n (nine) r a t h e r t h a n t h e group c o n d i t i o n (one ) . The number o f s u b j e c t s i n a r e l a t i o n - s h i p was s i g n i f i c a n t l y d i f f e r e n t (77.3% f o r t h e t r e a t e d c o n d i t i o n and 43.8% f o r t h e w a i t - l i s t c o n t r o l c o n d i - t i o n ) , and t h e number who p r e s e n t e d a s i g n i f i c a n t o t h e r a t p r e - t e s t and p o s t - t e s t was a l s o s i g n i f i c a n t l y d i f f e r e n t (63.6% f o r the t r e a t e d c o n d i t i o n and 18.8% f o r the w a i t - l i s t c o n t r o l c o n d i t i o n ) . In a d d i t i o n i t was found t h a t t h e two c o n d i t i o n s d i f f e r e d s i g n i f i c a n t - l y on t h e d u r a t i o n o f the a l c o h o l prob lem (5.82 y e a r s f o r the t r e a t e d c o n d i t i o n and 2.56 y e a r s o f t h e w a i t - l i s t c o n t r o l c o n d i t i o n ) . However, these d i f f e r e n c e s were on a m i n o r i t y o f d imens ions and not on t h e c r i t i - c a l d i m e n s i o n s o f a l c o h o l consumpt ion . T a b l e 4 summa- r i z e s the p r e - t e s t r e s u l t s o f the v a r i o u s e x p e r i m e n t a l measures . No s i g n i f i c a n t d i f f e r e n c e s were found on any o f these f i v e measures . Thus i t was c o n c l u d e d t h a t t h e s u b j e c t p o o l s were e s s e n t i a l l y s i m i l a r and t h a t d i f f e r - ences a t p o s t - t e s t c o u l d t h e r e f o r e be a t t r i b u t e d t o 130 Table 3 Characterist ics of Cl ients i n Treatment and Wai t - l i s t Groups: Hypothesis 2 Soc ia l and Demographic Variables Variable Treated (n=22) Wai t - l i s t Control (n=16) Age(years) M 37.23 35.31 SD 9.73 7.93 Education(years) M 13.68 13.38 SD 2.12 2.09 ••Duration M 5.82 2.56 SD 4.34 1.67 Sex Males 54.50% 37.50% Females 45.50% 62.50% •Relationship Couple 77.30% 43.80% Single 22.70% 56.30% Employment Employed 77.30% 87.50% Unemployed 22.70% 12.50% Family History Drinking Problem 54.50% 68.80% No Drinking Problem 45.50% 31.30% ••Signi f icant Other Present pre and post-test 63.60% 18.80% Not present at both 36.40% 81.30% • p<.05 • • p<.01 131 Table 4 Characterist ics of Clients i n Treatment and Wai t - l i s t Groups: Hypothesis 2 Alcohol Consumption and Related Pre-Test Measures Variable Treated(n=22) Wai t - l i s t Control (n=16) Weekly Consumption M 28.20 25.44 SD 10.70 15.92 Peak Consumption M 9.75 8.69 SD 4.41 3.74 L i f e Sat isfact ion Problem Checklist M 27.50 25.36 SD 3.83 4.53 Prof i l e of Mood States M 54.45 49.21 SD - 55.18 41.89 Social Adjustment Scale M 1.82 2.00 SD .46 .46 Michigan Alcoholism Screening Test M 13.25 13.21 SD 11.18 7.59 132 e v e n t s a f t e r the p r e - t e s t , such as t r e a t m e n t o r the l a c k o f t r e a t m e n t . T a b l e 5 and 6 d e s c r i b e t h e demographic d a t a o f t h e e n t i r e s u b j e c t sample o f t h i r t y - e i g h t i n d i v i d u a l s . The n o m i n a l d a t a i n t a b l e 5 r e f e r s t o those f i g u r e s which a r e p r e s e n t e d most m e a n i n g f u l l y as whole numbers w h i l e t h e r a t i o d a t a i n t a b l e 6 r e f e r s t o t h o s e w i t h which means and s t a n d a r d d e v i a t i o n s a r e more m e a n i n g f u l l y u s e d . T h i r t y - e i g h t i n d i v i d u a l s p a r t i c i p a t e d i n t h i s s t u d y . E i g h t e e n were male and twenty f emale , twen- t y - f o u r were i n v o l v e d i n a s t a b l e r e l a t i o n s h i p w h i l e f o u r t e e n were n o t , t h i r t y - o n e were employed and seven were unemployed, and t w e n t y - t h r e e r e p o r t e d a p r e v i o u s f a m i l y h i s t o r y o f a l c o h o l consumpt ion prob lems w h i l e f i f t e e n i n d i c a t e d no p r e v i o u s a l c o h o l prob lems i n t h e i r f a m i l y h i s t o r i e s . Independent c o l l a b o r a t i o n through i n t e r v i e w s w i t h s i g n i f i c a n t o t h e r s was a v a i l a b l e f o r 66% o f t h e c l i e n t s on a t l e a s t one t e s t i n g o c c a s i o n and 47% a t b o t h 133 Table 5 Ncminal Democrraphic Data for Entire Study Sample Variable Gender 18 male 20 female Stable Relationship 24 involved 14 single Employment 31 employed 7 unemployed Family History of 23 alcohol prob. 15 no alcohol Alcohol Problems i n family prob. in family Table 6 Ratio Democrraphic Data for Entire Study Sample (n=38) Variable Mean Standard Deviation Age (years) 36. 42 8. ,95 Education '(years) 13. 55 2. ,09 Duration of Problem (years) 4. 45 3. ,80 I n i t i a l Contact Weekly Drinking (drink units) 28. 08 12. .61 I n i t i a l Contact Peak Day Drinking (drink units) 9. 17 4. .02 Pretest Interview Weekly Drinking (drink units) 26. 97 13, .14 Pretest Interview Peak Day Drinking 9. 28 4, .10 L i f e Satisfaction Scale 26. 62 4. .21 Prof i l e of Mood States 52. 29 49. .51 Weissman Social Adjustment Scale 1. 89 .46 Michigan Alcoholism Screening Test 13. 24 9 .73 134 p r e - t e s t and p o s t - t e s t . S i g n i f i c a n t o t h e r v e r i f i c a t i o n a t b o t h d a t a p o i n t s was a v a i l a b l e f o r 25% o f t h o s e i n t h e i n d i v i d u a l c o n d i t i o n , 69% o f t h o s e i n t h e group c o n d i t i o n , and 25% o f those on the w a i t - l i s t . A l l b u t one s i g n i f i c a n t o t h e r v a l i d a t e d the c l i e n t ' s s e l f - r e p o r t o f approx imate consumpt ion and t h e one d i f f e r - ence o f r e c a l l e d consumption t h a t a r o s e was q u i c k l y r e s o l v e d w i t h a d d i t i o n a l c l a r i f y i n g d a t a by the c l i e n t . An e q u a l number o f c l i e n t s i n each c o n d i t i o n were t r e a t e d by each t h e r a p i s t . A c o r r e l a t i o n m a t r i x was c r e a t e d i n w h i c h the v a r i a b l e o f t h e r a p i s t was c o n - t r a s t e d a g a i n s t a l l o t h e r p r e - t e s t i n - t r e a t m e n t and p o s t - t e s t measures . A g a i n s t t h i s f i e l d o f f o r t y measures t h e v a r i a b l e o f t h e r a p i s t was found t o be s i g n i f i c a n t l y c o r r e l a t e d t o o n l y one, t h a t o f d u r a t i o n o f d r i n k i n g prob lem (r= .32 , p<.029) a t p r e - t e s t , and no v a r i a b l e s a t e i t h e r m i d - t r e a t m e n t o r p o s t - t e s t . Thus i t was c o n c l u d e d t h a t the e f f e c t s o f b o t h t h e r a p i s t s were e s s e n t i a l l y e q u i v a l e n t and t h a t t h e samples f o r each t h e r a p i s t c o u l d be combined f o r l a t e r c o n t r a s t s . 135 The mean age o f the sample was 3 6 . 4 y e a r s , t h e average e d u c a t i o n was 13.5 y e a r s , the average d u r a t i o n o f d r i n k i n g prob lems p r i o r to t r e a t m e n t was 4 . 5 y e a r s . A t t h e i n i t i a l c o n t a c t t e l e p h o n e s c r e e n i n g the mean a l c o h o l consumpt ion p e r week was 28.08 d r i n k u n i t s p e r week w i t h a h i g h e s t d a i l y consumption mean o f 9.17 d r i n k u n i t s ( d r i n k u n i t s are a common measure i n t h e f i e l d , see M i l l e r and Munoz 1982, one d r i n k u n i t i s e q u i v a l e n t t o a g l a s s o f beer o r wine , and s l i g h t l y more t h a n a one ounce g l a s s o f l i q u o r ) . A t t h e t i m e o f t h e p r e - t e s t i n t e r v i e w the mean weekly consumpt ion i n the s tudy sample was 26.97 d r i n k u n i t s w i t h a mean peak day consumption o f 9.28 d r i n k u n i t s . On t h e L i f e S a t i s f a c t i o n S c a l e a t p r e - t e s t , a b r i e f prob lem c h e c k l i s t w i t h a p o t e n t i a l range o f e i g h t t o f o r t y , t h e h i g h e r s c o r e i n d i c a t i n g the g r e a t e r c a p a c i t y t o mas ter problems o f d a i l y l i v i n g a d e q u a t e l y , the mean was 2 6 . 6 2 . On the P r o f i l e o f Mood S t a t e s , a p r o f i l e o f dominant moods w i t h i n the most r e c e n t week i n w h i c h the h i g h e r s c o r e i n d i c a t e s a g e n e r a l l y more 136 n e g a t i v e mood, the mean s c o r e was 5 2 . 2 9 . On the Weissman S o c i a l Adjustment S c a l e , a measure o f g e n e r a l f u n c t i o n i n g i n the environment i n which a h i g h e r s c o r e i n d i c a t e s a lower l e v e l o f community f u n c t i o n i n g , the mean was 1 .89 . On the M i c h i g a n A l c o h o l i s m S c r e e n i n g T e s t a d e v i c e f o r a s s e s s i n g s e v e r i t y o f a l c o h o l p r o b - lems i n which a h i g h e r s c o r e i n d i c a t e d g r e a t e r s e v e r i - t y , t h e mean s c o r e was 13 .24 . S i n c e t h e L i f e S a t i s f a c t i o n Q u e s t i o n n a i r e was a c l i n i c a l i n s t r u m e n t deve loped and i n use by t h e program a t t h e t i m e o f the s tudy b u t one on which r e l i a b i l i t y had n e v e r been a s s e s s e d , a C r o n b a c h ' s A l p h a was c a l c u - l a t e d on 'the p r e - t e s t s c o r e s and found t o be .84 , a r e s p e c t a b l e l e v e l f o r a measurement d e v i c e . I t was a l s o found t h a t t h i s s c a l e was s i g n i f i c a n t l y c o r r e l a t e d w i t h t h e p r e - t e s t s c o r e s on the P r o f i l e o f Mood S t a t e s (r= - . 6 8 , s i g n i f i c a n t p r o b a b i l i t y beyond . 001 ) . I t a p p e a r s i n f a c t t h a t the L i f e S a t i s f a c t i o n , P r o f i l e o f Mood S t a t e s , and Weissman S o c i a l Adjus tment S c a l e a r e a l l h i g h l y i n t e r r e l a t e d , and perhaps a l l are s u b c a t e g o - r i e s t o a g e n e r a l f u n c t i o n i n g l e v e l . 137 The M i c h i g a n A l c o h o l i s m S c r e e n i n g T e s t s c o r e s average w i t h t h i s sample are somewhat lower a t 13.24 t h a n t h o s e o f found i n samples used i n p r e v i o u s s t u d i e s and r e v i e w e d i n Chapter 3. T h i s r e s u l t sugges t s t h a t t h i s sample c o n s i s t s o f e a r l y s tage problem d r i n k e r s , perhaps a s u b j e c t sample which e x p e r i e n c e d l e s s s e v e r e d r i n k i n g problems than was found i n p r e v i o u s s t u d i e s . T h i s i s i n agreement w i t h a compar i son o f d r i n k i n g l e v e l s which i n d i c a t e s t h a t the mean p r e - t r e a t m e n t d r i n k i n g l e v e l o f c l i e n t s i n t h e program p r i o r t o t h i s s t u d y was 35 d r i n k u n i t s p e r week (Adams, 1983) as compared t o t h e mean p r e - t e s t d r i n k i n g l e v e l o f t h e c u r r e n t sample o f 2 6.97 d r i n k u n i t s p e r week. S e c t i o n Two: P o s t - t e s t S t a t i s t i c a l C o n t r a s t s T h i s s e c t i o n d e s c r i b e s the s t a t i s t i c a l c o n t r a s t s c a r r i e d out i n o r d e r t o a s s e s s the v a l i d i t y o f the two h y p o t h e s i s p u t forward i n t h i s s t u d y . The c o n t r a s t s a r e p r e s e n t e d i n two s u b s e c t i o n s , r e l e v a n t t o each h y p o t h e s i s . 138 ( i ) C o n t r a s t s T e s t i n g H y p o t h e s i s One The f i r s t h y p o t h e s i s sugges ted t h a t t r e a t m e n t u s i n g a group format would be s u p e r i o r i n terms o f outcome t o a t r e a t m e n t u s i n g an i n d i v i d u a l f o r m a t . In o r d e r t o compare the group t rea tment t o t h e i n d i v i d u a l t r e a t m e n t i t was f i r s t n e c e s s a r y t o e s t a b - l i s h t h a t the two groups i n t h e group t r e a t m e n t c o n d i - t i o n , which were c a r r i e d out s e q u e n t i a l l y and u s i n g d i f f e r e n t t h e r a p i s t s , were s i m i l a r and c o u l d t h e r e f o r e be combined. Thus d i f f e r e n c e s found i n c o n t r a s t s may be more e a s i l y a t t r i b u t e d t o t h e t r e a t m e n t s t h e m s e l v e s . A n a l y s i s o f c o v a r i a n c e was used i n o r d e r t o a d j u s t f o r t h e i n i t i a l o r b a s e l i n e d i f f e r e n c e s on the v a r i o u s measures , t h a t i s each p o s t - t e s t c o n t r a s t used t h e p r e - t e s t r e s u l t on t h a t p a r t i c u l a r measures as a c o v a r i a t e . The r e s u l t s a r e as f o l l o w s : f o r weekly a l c o h o l consumpt ion the two groups were not s i g n i f i c a n t l y 139 d i f f e r e n t (F=.91 , p<.36 , d . f . 1,12) , f o r peak day d r i n k i n g consumpt ion t h e r e was no s i g n i f i c a n t d i f f e r - ence (F=1.97, p<.19 , d . f . 1, 12) , f o r L i f e S a t i s f a c t i o n Table 7 Hypothesis One: Post-test Analysis of Covariance Conparisons to Assess S imi lar i ty of Sub Groups: Group One and Group Two of the Group Treatment Condition Variable Group 1 Group 2 Weekly Consumption Peak Consumption L i f e Sat isfact ion Prof i l e of Mood States Social Adjustment Scale 13.38 n=8 4.75 n=8 29.67 n=3 2.33 n=3 1.34 n=3 23.43 n=7 7.14 n=7 26.80 n=5 18.60 n=5 1.86 n=5 B̂ease nabs trd: cell siaas ae rxBsatBd in the somayt±flesalcrgwilh1henBa^ tvyjn1 fry girjiififTma- 140 t h e r e was no s i g n i f i c a n t d i f f e r e n c e (F=2.41, p<.18, d . f . 1, 5 ) , f o r P r o f i l e o f Mood s t a t e s c o r e s t h e r e was no s i g n i f i c a n t d i f f e r e n c e (F=1.72, p<.25 , d . f . 1, 5 ) , and f o r S o c i a l Adjustment S c a l e s c o r e s t h e r e was no s i g n i f i c a n t d i f f e r e n c e (F=.90, p<.39, d . f . 1, 5 ) . These r e s u l t s a r e summarized i n T a b l e 7. I t was c o n c l u d e d t h a t the two groups o f the group t r e a t m e n t c o n d i t i o n were not s i g n i f i c a n t l y d i f f e r e n t and c o u l d t h u s be combined f o r c o n t r a s t w i t h t h e i n d i v i d u a l t r e a t m e n t c o n d i t i o n . The i n d i v i d u a l c o n d i t i o n c o n s i s t e d o f one group o f seven who were not on the w a i t - l i s t and a n o t h e r group o f n i n e who were. An a n a l y s i s o f c o v a r i a n c e was c a r r i e d out on these two groups t o e s t a b l i s h t h a t they were e s s e n t i a l l y s i m i l a r and c o u l d t h e r e f o r e be com- b i n e d f o r c o n t r a s t w i t h t h e group c o n d i t i o n . T h i s re sponds t o p o s s i b l e c r i t i c i s m t h a t b e i n g p u t on a w a i t l i s t p r i o r t o t rea tment would i t s e l f have a s i g n i f i c a n t impact on t h e s u b j e c t s . On t h i s s e r i e s o f c o n t r a s t s t h e f o l l o w i n g r e s u l t s were p r o d u c e d : on weekly c o n - sumpt ion o f a l c o h o l t h e r e was no s i g n i f i c a n t d i f f e r e n c e 141 found (F=.77 , p<.40, d . f . 1, 11) , on peak d a i l y c o n - sumpt ion no s i g n i f i c a n t d i f f e r e n c e was found Table 8 Hypothesis One: Post-test Analysis of Covariance Comparisons to Assess s i m i l a r i t y of Sub-crroups: Previously Wait - l i s ted and Not Previously Wait- l i s ted Subjects of the Individual Treatment Condition Variable Wait- l is ted Not Wait- l is ted Weekly Consumption 12.56 n=9 16.60 n=5 Peak Consumption 4.78 n=9 6.40 n=5 L i f e Sat is fact ion 26.25 n=8 31.60 n=5 Pro f i l e of Mood States 33.63 n=8 19.20 n=5 Social Adjustment Scale 1.96 n=8 1.58 n=5 142 (F=1.58, jx .24, d . f . 1, 11), cai the Li fe Satisfaction scores there was no s ignif icant difference found (F=1.43, p<.26, d . f . 1,10), on the Prof i l e of Mood State scores there was no s ignif icant d i f f e r - ence (F=.59, p<.46, d . f . 1,10), and cn the Social Adjustment scores there was found to be no s ignif icant difference (F=.22, p<.65, d . f . 1,10). These results are summarized i n Table 8. Thus i t was concluded that there was no essential difference between those i n the individual condition who had i n i t i a l l y experienced the w a i t - l i s t condition and those who had not. As a result these two sub-groups were combined into the overal l individual condition for la ter contrasts with the group treatment condition. The major contrasts for th i s hypothesis were tested next. The group condition was contrasted with the individual condition on the major variables. The results of these contrasts were as follows: no s ignif icant difference was found i n contrasts using weekly alcohol consumption (P=.43, p<.52, d . f . 1, 26), peak da i ly consumption (F=. l l , px.74 d . f . , 1, 26), L i f e Satisfaction scores (F=.00, p<.96, d . f . , 1, 18), Prof i le of Mood State scores (F=1.46, p<-24, d . f . , 1, 18), or on Social Adjustment Scores (F=.70, p<.41, d . f . , 1, 18). 143 Table 9(a) Major Contrasts of Hypothesis One: Analysis of Covariance Contrasts Between Group Treatment and Individual Treatment Post-Test Variable Group Treatment Individual Treatment Weekly Consumption 18. 07 n=15 14.00 n=14 Peak Consumption 5. 87 n=15 5.36 n=14 L i f e Satisfaction 27. 88 n=8 28.31 n=13 Prof i l e of' Mood States 12. 50 n=8 28.08 n=13 Social Adjustment Scale 1. 66 n=8 1.82 n=13 144 Table 9 (b) Six Month Follow-up Variable Group Treatment Individual Treatment Weekly Consumption 18.38 n=13 16. 08 n=13 Peak Consumption 6.08 n=13 5. 23 n=13 L i f e Satisfaction 30.83 n=12 28. 62 n=13 Prof i l e of Mood States 8.50 n=12 22. 08 n=13 Social Adjustment Scale 1.63 n=12 1. 84 n=12 145 S i x month f o l l o w - u p d a t a was a l s o a n a l y z e d . On t h e weekly a l c o h o l consumpt ion d a t a no s i g n i f i c a n t d i f f e r e n c e was found (F=.08, p<.78 , d . f . 1, 2 3 ) . On t h e peak d a i l y consumpt ion no s i g n i f i c a n t d i f f e r e n c e was found (F=.19, p<.67, d . f . 1, 2 3 ) . On t h e L i f e S a t i s f a c t i o n S c a l e s c o r e s no s i g n i f i c a n t d i f f e r e n c e was found (F=1.35, p<.26, d . f . 1, 2 2 ) . No s i g n i f i c a n t d i f f e r e n c e was found on P r o f i l e o f Mood S t a t e s c o r e s (F=.96 , p<.34, d . f . 1, 22 ) , and no s i g n i f i c a n t d i f f e r - ence was found on S o c i a l Adjus tment s c o r e s (F=2.24, p<.13 , d . f . 1, 2 1 ) . These r e s u l t s a r e summarized on T a b l e s 9(a) and 9 ( b ) . A p l o t o f t h e changes i n d r i n k i n g l e v e l s o v e r t h e c o u r s e o f t r e a t m e n t i s i n c l u d e d i n F i g u r e 3 . Thus i t was c o n c l u d e d t h a t t h e r e was no s i g n i f i - c a n t d i f f e r e n c e i n outcomes between group and i n d i v i d u - a l t r e a t m e n t f o r m a t s . As a r e s u l t the f i r s t h y p o t h e - s i s , t h a t t r e a t m e n t u s i n g a group format i s s u p e r i o r t o t r e a t m e n t u s i n g an i n d i v i d u a l f o r m a t , i s n o t s u p p o r t e d . 146 I'STWC FUTWC I'SWC S 1 W C C o n s u m P t i o n P o s t - T e s t Weekly Consumpt. i on l ro 1 I ow-up week I y Consuiupt i on I'lionu S c r e e n i n g Weekly Cons limp t i on S c r e e n i n g I n t e r v i e w Wcri ' k I y Consiunpt 1 on 35 FIGURE 3 Weekly Consumption i i | r i i r PSWC SHYC "rTEEK2 TVEEK3 WEEK4 T?T1EK5 WEEK6 "rVEEK7 WEEK8 PSTWC FUPTYC ( i i ) C o n t r a s t s T e s t i n g H y p o t h e s i s Two The second h y p o t h e s i s was t h a t t r e a t m e n t u s i n g the program d e s i g n e d f o r t h i s s tudy was s u p e r i o r i n outcome t o no t r e a t m e n t . T h i s r e q u i r e d t h a t the t r e a t m e n t c o n d i t i o n s be combined i n o r d e r t o be c o n t r a s t e d t o the u n t r e a t e d s u b j e c t s . The n o - t r e a t m e n t c o n d i t i o n c o n - s i s t e d o f a w a i t - l i s t o f e q u a l l e n g t h t o t h e t r e a t m e n t c o n d i t i o n . Due t o the requ irement f o r independence o f samples t h e s u b j e c t s who were i n c l u d e d i n t h e w a i t - l i s t c o n d i t i o n and t h e n p l a c e d i n t rea tment were removed from the d a t a o f t r ea tment c o n d i t i o n s . T h i s made the sample s i z e s o f the t r e a t m e n t c o n d i t i o n s f i f t e e n f o r t h e group c o n d i t i o n , seven f o r t h e i n d i v i d u a l c o n d i - t i o n , o r a t o t a l o f twenty two f o r the combined t r e a t - ment c o n d i t i o n . Two o f t h e members o f t h e i n d i v i d u a l c o n d i t i o n dropped out p r i o r t o c o m p l e t i o n o f t r e a t m e n t so t h a t d a t a were a v a i l a b l e on a t o t a l o f twenty t r e a t e d s u b j e c t s . S i x t e e n s u b j e c t s were a s s i g n e d t o t h e w a i t - l i s t c o n d i t i o n and d a t a are a v a i l a b l e on a l l o f them. ( 148 C o n t r a s t s o f the t r e a t e d v e r s u s the u n t r e a t e d s u b j e c t s were made w i t h r e s p e c t to d r i n k i n g l e v e l s a t t h e p o s t - t e s t p o s i t i o n . A n a l y s i s o f c o v a r i a n c e was u s e d i n o r d e r t o a d j u s t f o r t h e i n i t i a l o r b a s e l i n e i n d i v i d u a l d i f f e r e n c e s i n d r i n k i n g l e v e l s . In o r d e r t o combine the two groups o f t h e group c o n d i t i o n an i n i t i a l a n a l y s i s o f c o v a r i a n c e was c a r r i e d o u t between the g r o u p s . T h i s i s r e p o r t e d i n T a b l e 10. I t was found t h a t no s i g n i f i c a n t d i f f e r e n c e e x i s t e d between t h e s e groups a t p o s t - t e s t on e i t h e r weekly a l c o h o l consumpt ion (F=.19, p<.67, d . f . 1, 11) o r peak day a l c o h o l consumption (F=1.49, p<.25, d . f . 1, 11) . t An a n a l y s i s o f c o v a r i a n c e u s i n g L i f e S a t i s f a c t i o n s c o r e s a l s o r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e (F=2.41, p< .18 , d . f . 1, 5 ) . S i m i l a r l y w i t h P r o f i l e o f Mood S t a t e s no s i g n i f i c a n t d i f f e r e n c e was found (F=1.72, p< .25 , d . f . 1, 5) as was a l s o found t o be t h e case f o r S o c i a l Adjus tment Scores (F=.90, p<.39, d . f . 1, 5 ) . Thus i t was c o n c l u d e d t h a t t h e two groups o f the group t r e a t m e n t c o n d i t i o n were e s s e n t i a l l y s i m i l a r and c o u l d be combined. 149 Table 10 Hypothesis Two: Post Test Analysis of Covariance Comparisons to Assess S imi lar i ty of Sub-Groups (with those previously on Wai t - l i s t deleted) Group one and Group Two of the Group Treatment Condition Variable Group 1 Group 2 Weekly Consumption 13. 38 n=8 22.33 n=6 Peak Consumption 4. 75 n=8 7.17 n=6 L i f e Satisfaction 29. 67 n=3 26.80 n=5 Prof i l e of'Mood States 2. 33 n=3 18.60 n=5 Social Adjustment Scale 1. 34 n=3 1.86 n=5 150 Next , c o n t r a s t s were c a r r i e d out between t h i s combined group t rea tment (wi th the one p e r s o n who a l s o appeared i n t h e w a i t - l i s t removed) and t h e r e m a i n i n g s u b j e c t s i n t h e i n d i v i d u a l c o n d i t i o n once t h o s e who a l s o appeared i n the w a i t - l i s t c o n d i t i o n were removed ( l e a v i n g seven s u b j e c t s ) . The purpose o f t h e s e c o n - t r a s t s was t o a s se s s whether the group s u b j e c t s and t h e i n d i v i d u a l s u b j e c t s were s i m i l a r so t h a t t h e y c o u l d be combined i n t o a g e n e r a l t rea tment group f o r c o n t r a s t w i t h the w a i t - l i s t c o n d i t i o n . The f i r s t a n a l y s i s o f c o v a r i a n c e c o n t r a s t e d group and i n d i v i d u a l t r ea tment s u b j e c t s on weekly a l c o h o l consumpt ion and found no s i g n i f i c a n t d i f f e r e n c e (F=.03 , p< .86 , d . f . 1, 16) . S i m i l a r l y a c o n t r a s t u s i n g peak day a l c o h o l consumpt ion showed no s i g n i f i c a n t d i f f e r - ence (F=.09 , p<.77 , d . f . 1, 16) , as d i d t h e c o n t r a s t s u s i n g L i f e S a t i s f a c t i o n s c o r e s (F=2.72, p< .13 , d . f . 1, 10 ) , P r o f i l e o f Mood S t a t e S c o r e s (F=55, p< .47 , d . f . 1, 10 ) , and S o c i a l Adjustment s c o r e s (F= .01 , p< .94 , d . f . 1, 10 ) . These r e s u l t s a r e summarized i n T a b l e 11. I t was c o n c l u d e d t h a t the t r e a t e d s u b j e c t s were s i m i l a r 151 and c o u l d be combined i n o r d e r t o c o n t r a s t w i t h n o - t r e a t m e n t w a i t - l i s t c o n t r o l s u b j e c t s . Table 11 Post-test Analysis of Covariance to Assess S imi lar i ty of Sub- Groups Group Treatment and Individual Treatment Subjects Variable Group Treatment Individual Treatment Weekly Consumption 17.21 n=14 16.60 n=5 Peak Consumption 5.79 n=14 6.40 n=5 L i f e Sat isfact ion 27.88 n=8 31.60 n=5 P r o f i l e of Mood States 12.50 n=8 19.20 n=5 Socia l Adjustment Scale 1.66 n=8 1.58 n=5 152 C o n t r a s t s were t h e n per formed between the t r e a t e d s u b j e c t s ( e x c l u d i n g t h o s e who had a l s o appeared on t h e w a i t - l i s t c o n t r o l group) and the n o n - t r e a t e d s u b j e c t s i n o r d e r t o a s se s s the v a l i d i t y o f the second h y p o t h e - s i s ; t h a t t r e a t m e n t u s i n g t h i s program i s s u p e r i o r i n outcome t o n o - t r e a t m e n t . The f i r s t a n a l y s i s o f c o v a r i a n c e c o n t r a s t e d t r e a t e d and n o n - t r e a t e d s u b j e c t s on weekly a l c o h o l c o n s u m p t i o n and found a s i g n i f i c a n t e f f e c t f o r t r e a t - ment (F=5.47, p<.03, d . f . 1, 32 ) . The mean weekly c o n s u m p t i o n l e v e l o f t h e t r e a t e d group was 17.05 d r i n k u n i t s w h i l e t h a t o f t h e w a i t l i s t was 25.81 p e r week. I n t h e c o n t r a s t u s i n g peak d a i l y a l c o h o l consumpt ion a d i f f e r e n c e a p p r o a c h i n g s i g n i f i c a n c e was found between t r e a t e d and n o n - t r e a t e d s u b j e c t s (F=3.47, p<.07, d . f . 1, 3 2 ) . The mean peak d a i l y consumpt ion l e v e l o f t h e t r e a t e d sample was 5.95 d r i n k u n i t s w h i l e t h a t o f t h e w a i t - l i s t sample was 8.19 d r i n k u n i t s on the h i g h e s t day p e r week. These r e s u l t s a r e summarized i n T a b l e 12. 153 I t was c o n c l u d e d t h a t t rea tment u s i n g t h i s program p o s i t i v e l y and s i g n i f i c a n t l y a f f e c t s outcome. Table 12 Major Contrasts of Hypothesis Two: Analysis of Covariance Contrasts Between Treated and W a i t - l i s t Control Subjects (with subjects previously on w a i t - l i s t deleted from the treated subject pool) Variable Treated Wai t - l i s t Control •Weekly Consumption 17.05 n=19 25.81 n=16 Peak Consumption 5.95 n=19 8.19 n=16 *sig <.05 In a f i n a l c o n t r a s t , i n o r d e r t o e x p l o r e f u r t h e r t h e r e l a t i o n s h i p between group t r e a t m e n t , i n d i v i d u a l t r e a t m e n t , and w a i t - l i s t c o n t r o l , and o r t h o g o n a l c o m p a r i s o n was c a r r i e d out between the t h r e e c o n d i - t i o n s . 154 F o r t h i s compar i son those s u b j e c t s who appeared i n t h e w a i t - l i s t c o n d i t i o n and l a t e r i n a t r e a t m e n t c o n d i t i o n were removed from c o n s i d e r a t i o n i n t h e t r e a t m e n t c o n d i t i o n to ensure independence o f samples . As a r e s u l t the sample s i z e o f the t h r e e c o n d i t i o n s a r e 15 f o r t h e group c o n d i t i o n , 5 f o r the i n d i v i d u a l c o n d i t i o n , and 16 f o r the w a i t - l i s t c o n d i t i o n . C o n - t r a s t s used o n l y p o s t - t e s t weekly a l c o h o l consumpt ion and peak a l c o h o l consumpt ion . R e s u l t s o f t h e s e c o n - t r a s t s a r e r e p o r t e d i n t a b l e s 13 ( a ) , (b ) , and (c) and 14 (1) , (b) , and (c) . In a c o n t r a s t o f group and i n d i v i d u a l t r e a t m e n t c o n d i t i o n s weekly a l c o h o l consumpt ion , no s i g n i f i c a n t d i f f e r e n c e was found (T=.07, p< .95 ) . In a c o n t r a s t o f group t r e a t m e n t and w a i t - l i s t c o n d i t i o n weekly a l c o h o l c o n s u m p t i o n , no s i g n i f i c a n t d i f f e r e n c e was found (T=1.34, p< .19 ) . The c o n t r a s t between i n d i v i d u a l t r e a t m e n t and t h e w a i t - l i s t c o n d i t i o n s i m i l a r l y found no s i g n i f i c a n t d i f f e r e n c e (T=1.03, p<.31) n o r d i d the c o n t r a s t between the combined t rea tment c o n d i t i o n s and t h e w a i t - l i s t c o n d i t i o n (T=1.41, p< .17 ) . 155 A s e r i e s o f c o n t r a s t s were a l s o p e r f o r m e d on peak day a l c o h o l consumpt ion . In c o n t r a s t i n g group t r e a t - ment and i n d i v i d u a l t r ea tment no s i g n i f i c a n t e f f e c t was found ( T = - . 2 5 , p < . 8 0 ) / nor was a s i g n i f i c a n t e f f e c t found i n the c o n t r a s t o f group t rea tment and t h e w a i t - l i s t c o n d i t i o n (T=-1 .41 , p< .17) , t h e c o n t r a s t o f i n d i v i d u a l t r e a t m e n t and w a i t - l i s t c o n d i t i o n (T=- .75 , T a b l e 13 (a) Means and S t a n d a r d D e v i a t i o n s f o r t h e T h r e e E x p e r i m e n t a l C o n d i t i o n s on P o s t - T r e a t m e n t Weekly A l c o h o l Consumption C o n d i t i o n N Mean S t a n d a r d D e v i a t i o n Group 14 17.21 14 .95 I n d i v i d u a l 15 16. 60 8.14 W a i t - l i s t 16 25.81 21. 08 T o t a l 35 21.06 17.58 156 T a b l e 13 (b) A n a l y s i s o f V a r i a n c e f o r t h e T h r e e E x p e r i m e n t a l C o n d i t i o n s on P o s t - T r e a t m e n t Weekly Consumption S o u r c e DF Sum o f Mean F S i g n i f i c a n c e Squares Squares o f F Between Groups 2 667.89 333.95 1.09 .35 W i t h i n Groups 32 9839.99 307.50 T o t a l 34 10507.89 T a b l e 13 (c) O r t h o g o n a l C o n t r a s t s o f C o n d i t i o n s on P o s t - T r e a t m e n t Weekly Consumption _ i _____ C o n t r a s t V a l u e S t a n d a r d T DF T E r r o r V a l u e P r o b a b i l i t y Group v s . I n d i v i d - u a l Trea tment s .61 9.14 .07 32 .95 Group v s . W a i t - L i s t C o n d i t i o n s - 8 . 6 0 6.42 -1 .34 32 .19 I n d i v i d u a l v s . W a i t - L i s t C o n d i t i o n s - 9 . 2 1 8.98 -1 .03 32 .31 Treatment v s . W a i t - L i s t C o n d i t i o n s - 8 . 9 1 6.33 - 1 . 4 1 32 .17 157 T a b l e 14 (a) Means and S t a n d a r d D e v i a t i o n s f o r the T h r e e C o n d i t i o n s on P o s t - T r e a t m e n t Peak Day A l c o h o l Consumption C o n d i t i o n N Mean S t a n d a r d D e v i a t i o n Group 14 5.79 4.42 I n d i v i d u a l 5 6.40 1.82 W a i t - L i s t 16 8.19 5.33 T o t a l 3:5 6.97 4.66 T a b l e 14 (b) A n a l y s i s o f v a r i a n c e f o r the t h r e e c o n d i t i o n s on P o s t - T r e a t m e n t Peak Day A l c o h o l Consumption i , S o u r c e DF Sum o f Mean F S i g n i f i c a n c e Squares Squares o f F Between Groups 2 44.98 22.49 1.04 .37 W i t h i n Groups 32 693.99 21.69 T o t a l 34 738.97 158 T a b l e 14 (c) O r t h o g o n a l C o n t r a s t s o f C o n d i t i o n s on P o s t - T r e a t m e n t Peak Day Consumption C o n t r a s t V a l u e S t a n d a r d E r r o r T V a l u e DF T P r o b a b i l i t y Group v s . I n d i v i d - u a l Trea tments - . 6 1 2.43 - . 2 5 32 .80 Group v s . W a i t - L i s t C o n d i t i o n s - 2 . 4 0 1.70 - 1 . 4 1 32 .17 I n d i v i d u a l v s . W a i t - L i s t C o n d i t i o n s -1 /79 2.39 - . 7 5 32 .46 Trea tment v s . W a i t - L i s t C o n d i t i o n s - 2 . 0 9 1.68 - 1 . 2 5 32 .22 p< .46 ) , o r the combined t r e a t m e n t s v e r s u s w a i t - l i s t c o n t r a s t (T=-1 .25 , p < . 2 2 ) . The o r t h o g o n a l c o n t r a s t s i n d i c a t e t h a t when a n a l y z e d by a n a l y s i s o f v a r i a n c e no s i g n i f i c a n t e f f e c t s can be a t t r i b u t - ed t o t r e a t m e n t , e i t h e r one t r e a t m e n t over a n o t h e r , one t r e a t m e n t i n compar i son t o the c o n t r o l c o n d i t i o n , o r com- b i n e d t r e a t m e n t s compared t o the c o n t r o l c o n d i t i o n . 159 I t s h o u l d be noted t h a t the o r t h o g o n a l c o n t r a s t c o u l d o n l y be c a r r i e d out on an a n a l y s i s o f v a r i a n c e p r o c e d u r e , n o t on a n a l y s i s o f c o v a r i a n c e which was used i n the main a n a l y s e s o f t h i s s tudy (Manual: S t a t i s t i c a l Package f o r t h e S o c i a l S c i e n c e s , N o r u s i s , 1988). As a r e s u l t t h e v a r i a n c e a t t r i b u t a b l e t o p r e - t e s t d i f f e r e n c e s was not c o n t r o l l e d , r e d u c i n g p o s t - t e s t c o n t r a s t s to n o n - s i g n i f i c a n c e and the o r t h o g o n a l comparisons a t p o s t - t e s t t o n o n - s i g n i f i c a n c e . I n summary, t h e r e f o r e , i t i s c o n c l u d e d t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e between group and i n d i v i d u a l f o r m a t s i n t h i s s t u d y . There was, however, a s i g n i f i c a n t d i f f e r e n c e between t r e a t e d and c o n t r o l s u b j e c t s , f a v o r i n g t h e t r e a t e d s u b j e c t s , on weekly a l c o h o l consumpt ion . T h i s e f f e c t s i z e was s i g n i f i c a n t a t t h e p<.05 l e v e l on a n a l y s i s o f c o v a r i a n c e . When the data were rev iewed t o e x p l o r e t r e a t m e n t e f f e c t s f u r t h e r i t was found t h a t e l e v e n i n the i n d i v i d u a l c o n d i t i o n decreased weekly a l c o h o l consumption o v e r the c o u r s e o f t rea tment by an average o f 16.5 S t a n d a r d D r i n k U n i t s . A t the same t i m e , t h r e e p e r s o n s i n c r e a s e d t h e i r c o n s u m p t i o n by an average o f 10.3 d r i n k s . The maximum 160 d e c r e a s e i n d r i n k i n g was 33 d r i n k s w h i l e the maximum i n - c r e a s e was 17 d r i n k s . In t h e group c o n d i t i o n twelve p e r s o n s d e c r e a s e d t h e i r weekly a l c o h o l consumpt ion by an average o f 15 D r i n k U n i t s and a maximum o f 29 U n i t s w h i l e two i n c r e a s e d t h e i r a l c o h o l consumpt ion by an average o f 16 S t a n d a r d D r i n k U n i t s and a maximum o f 20 U n i t s . One remained the same. I t becomes c l e a r t h a t the o v e r a l l tendency i s toward d e c r e a s i n g c o n - sumpt ion y e t t h e r e i s l i t t l e d i f f e r e n c e between group and i n d i v i d u a l f o r m a t s . From the above d a t a i t i s c l e a r t h a t t h e m a j o r i t y b e n e f i t t e d from t r e a t m e n t , d e c r e a s i n g a l c o h o l consumpt ion an average o f 15.7 S t a n d a r d D r i n k U n i t s by t h e p o s t - t e s t week as compared to the s c r e e n i n g i n t e r v i e w p r e - t e s t . A m i n o r i t y , f i v e i n d i v i d u a l s , d e t e r i o r a t e d o v e r t h e c o u r s e o f t r e a t m e n t , i n c r e a s i n g t h e i r consumpt ion an average o f 12.6 U n i t s . The program t h u s appears g e n e r a l l y t o be h e l p f u l , a l t h o u g h i t may be l e s s h e l p f u l f o r a s m a l l m i n o r i t y . 161 C h a p t e r 5 D i s c u s s i o n Review o f Hypotheses and C o n c l u s i o n s Two hypotheses were proposed i n t h i s s t u d y . The f i r s t and c e n t r a l h y p o t h e s i s was t h a t t r e a t m e n t u s i n g a group format would be s u p e r i o r t o t r e a t m e n t u s i n g an i n d i v i d u a l f o r m a t . The second h y p o t h e s i s was t h a t t r e a t m e n t u s i n g the c u r r e n t t r e a t m e n t package would be s u p e r i o r t o a w a i t l i s t . These hypotheses w i l l be rev i ewed and d i s c u s s e d be low, a l o n g w i t h the r e s u l t s o f t h e s t a t i s t i c a l c o n t r a s t s . L i m i t a t i o n s o f t h e c u r r e n t s t u d y a r e d i s c u s s e d , f o l l o w e d by i m p l i c a t i o n s o f t h i s s t u d y f o r 162 c o u n s e l i n g t r e a t m e n t and r e s e a r c h . S u g g e s t i o n s f o r f u r t h e r r e s e a r c h c l o s e the c h a p t e r . H y p o t h e s i s One The f i r s t h y p o t h e s i s sugges ted t h a t a group format t r e a t m e n t u s i n g t h e c u r r e n t t r e a t m e n t model would be s u p e r i o r i n outcome t o an i n d i v i d u a l format t r e a t m e n t . T h i s i s t h e c e n t r a l h y p o t h e s i s o f t h i s s t u d y . Based on a r e v i e w o f p r e v i o u s r e s e a r c h i n t o group t r e a t m e n t and i n d i v i d u a l t r e a t m e n t , e x p e r i m e n t a l r e s e a r c h i n t o the impact o f s o c i a l i n v o l v e m e n t , and a r e v i e w o f t h e t h e o r e t i c a l l y proposed impact o f group t r e a t m e n t , i t was proposed t h a t t h e r e e x i s t e d a u n i q u e and added impact from t r e a t m e n t which was d e l i v e r e d w i t h i n a group format as compared t o t h a t d e l i v e r e d i n an i n d i v i d u a l f o r m a t . I t was p r o p o s e d t h a t s e v e r a l t h e r a p e u t i c f a c t o r s were p r e s e n t i n a group t r e a t m e n t format t h a t were not a v a i l a b l e i n i n d i v i d u a l t r e a t m e n t . T h e s e t h e r a p e u t i c f a c t o r s were: i n t e r a c t i o n , c o h e s i v e - n e s s , and v i c a r i o u s l e a r n i n g . 163 S t a t i s t i c a l c o n t r a s t s r e v e a l e d t h a t t h e r e were no s t a t i s t i c a l l y s i g n i f i c a n t outcome d i f f e r e n c e s between t h e group and i n d i v i d u a l format c o n d i t i o n s on any o f t h e measures o f a l c o h o l consumpt ion o r l i f e f u n c t i o n i n g u s e d i n t h i s s tudy a t e i t h e r p o s t - t e s t f o l l o w i n g t r e a t m e n t o r a t t h e s i x month f o l l o w - u p . T h u s , i t was c o n c l u d e d t h a t t h e r e was no s u p p o r t f o r the f i r s t h y p o t h e s i s t h a t t r e a t m e n t u s i n g a group format would be s u p e r i o r t o t r e a t m e n t u s i n g an i n d i v i d - u a l f o r m a t . H y p o t h e s i s Two The second h y p o t h e s i s proposed t h a t t r ea tment u s i n g the c u r r e n t model would produce a r e s u l t s u p e r i o r t o a w a i t - l i s t c o n t r o l c o n d i t i o n . S t a t i s t i c a l c o n t r a s t s r e v e a l e d t h a t the d i f f e r e n c - es between the t r e a t e d and t h e w a i t - l i s t c o n t r o l s u b j e c t s was s i g n i f i c a n t on the c e n t r a l measure, weekly a l c o h o l consumpt ion , and a p p r o a c h i n g s i g n i f i c a n c e on t h e second measure, peak d a i l y a l c o h o l consumpt ion . 164 A t r e a t m e n t program had been d e s i g n e d s p e c i f i c a l l y f o r t h i s s t u d y u s i n g s e v e r a l d i f f e r e n t i n t e r v e n t i o n s o v e r a compact t ime p e r i o d . The i n t e r v e n t i o n s u t i l i z e d drew on work from p r e v i o u s r e s e a r c h e r s and were a r - ranged s e q u e n t i a l l y i n t o a s t r o n g o v e r a l l agenda. I t was proposed t h a t the r e s u l t i n g program would prove t o be a s u c c e s s f u l t rea tment program s i n c e i t i n c o r p o r a t e d components o f p r e v i o u s s u c c e s s f u l programs, was c a r e - f u l l y sequenced, and addressed both consumpt ion and o t h e r l i f e s t y l e o r h e a l t h p r o b l e m s . The mean weekly a l c o h o l consumption was 17.05 f o r t h e t r e a t e d s u b j e c t s f o l l o w i n g e i g h t weeks o f t r e a t m e n t and 25.81 f o r the w a i t - l i s t c o n t r o l s u b j e c t s a t the e i g h t week p o s t - t e s t , a s i g n i f i c a n t d i f f e r e n c e . The peak day consumpt ion per week was found t o be 5.95 d r i n k u n i t s f o r the t r e a t e d s u b j e c t s f o l l o w i n g t r e a t - ment and 8.19 d r i n k u n i t s f o r the w a i t - l i s t c o n t r o l group a t p o s t - t e s t . Thus i t was c o n c l u d e d t h a t the second h y p o t h e s i s was s u p p o r t e d and t h a t the t rea tment model was e f f e c - t i v e . 165 L i m i t a t i o n s o f T h i s Study The c u r r e n t program was d e v e l o p e d s p e c i f i c a l l y f o r t h i s s t u d y . One purpose i n d o i n g t h i s was t o d e v e l o p program c o n t e n t which would be t h e same a c r o s s b o t h t h e group and i n d i v i d u a l format . In a d d i t i o n , improvements on p r e v i o u s programs were a t t e m p t e d . A l o n g t h i s v i e w , t h e p r e s e n t program d i f f e r e d from p r e v i o u s e f f o r t s i n i t s compactness , e i g h t weeks as compared t o t h e p r e v i - ous t w e l v e week program at the r e s e a r c h s i t e , f o r example . I t a l s o p l a c e d a much h i g h e r emphasis on d e c i s i o n - m a k i n g t h a n o t h e r programs r e v i e w e d . T h i s f o l l o w e d the r e s e a r c h e r ' s p e r c e p t i o n t h a t w i l l and s k i l l a l o n e were i n s u f f i c i e n t f o r change and f r e q u e n t l y f a l t e r e d i n t h e f a c e o f p r e s s u r e . T h i s f a l t e r i n g was c o n s t r u e d t o o c c u r as a person may have r e s o l v e d t o r e d u c e d r i n k i n g w i t h o u t t a k i n g i n t o c o n s i d e r a t i o n t h e e m o t i o n a l s t a t e t h a t was a s s o c i a t e d w i t h t e m p t a t i o n s t o over -consume, t h e f u n c t i o n s o f a l c o h o l consumpt ion i n mee t ing p e r s o n a l needs or becoming l e s s aware o f them, t h e l i f e s t y l e changes i n v o l v e d i n r e d u c e d a l c o h o l c o n s u m p t i o n , o r many o t h e r f a c t o r s . Thus t h e program sought t o r e v i e w and t o complete more f u l l y t h e p r o c e s s 166 o f d e c i s i o n - m a k i n g i n a number o f d i f f e r e n t ways i n o r d e r t o produce l a s t i n g change. S e v e r a l l i m i t a t i o n s o f the c u r r e n t s t u d y may be s u g g e s t e d . One p o s s i b i l i t y r e f e r s t o t h e f a c t t h a t t h e c u r r e n t sample appeared t o be somewhat l e s s s e v e r e on t h e t a r g e t p r o b l e m o f a l c o h o l abuse t h a n samples used i n p r e v i o u s s t u d i e s . I t may be t h a t t h i s caused a ' f l o o r e f f e c t ' i n t h a t the degree o f improvement was hampered by a l i m i t e d a v a i l a b l e range from t h e i n i t i a l p r o b l e m d r i n k i n g l e v e l , a v e r a g i n g 26.97 d r i n k u n i t s p e r week, t o the t a r g e t s a f e r d r i n k i n g l e v e l o f 15 t o 18 d r i n k u n i t s p e r week o r l e s s . The impac t o f t h i s ' f l o o r e f f e c t ' on the outcome might be t h a t any p o t e n - t i a l d i f f e r e n c e between group and i n d i v i d u a l format would be l i m i t e d i n p o t e n t i a l r a n g e . Thus t h e d i f f e r - ence i n p o s t - t e s t means found, 18.07 d r i n k u n i t s f o r t h e group t r e a t m e n t format v e r s u s 14 .00 d r i n k u n i t s f o r t h e i n d i v i d u a l t r ea tment format was n o t s i g n i f i c a n t (and a l s o f a v o r s the i n d i v i d u a l format) but may have been so w i t h a more severe s u b j e c t p o p u l a t i o n i n terms o f h a v i n g g r e a t e r p r e - t e s t consumpt ion o f a l c o h o l . The 167 mean o f p r e v i o u s p o p u l a t i o n s a t t h e t e s t s i t e was 35 d r i n k u n i t s p e r week a t i n t a k e . A second p o s s i b l e p r o b l e m o f the c u r r e n t s tudy i s t h a t the t r e a t m e n t may n o t have been p o w e r f u l enough on some d imens ions i n o r d e r t o f u l l y d e v e l o p t h e p o t e n t i a l d i f f e r e n c e s between the two f o r m a t s . Gibb (1964) s u g g e s t s t h a t t ime and i n t e n s e invo lvement i s r e q u i r e d i n a group environment i n o r d e r t o deve lop and work t h r o u g h each o f t h e v a r i o u s s t a g e s o f t r u s t f o r m a t i o n , d a t a f l ow , g o a l f o r m a t i o n and s o c i a l c o n t r o l . Schutz ( i n Dimock, 1970) s i m i l a r l y p r o p o s e d t h a t a h i g h degree o f invo lvement would be r e q u i r e d t o p r o g r e s s t h r o u g h h i s p r o p o s e d s t a g e s o f membership, s t r u g g l e f o r c o n - t r o l , c o h e s i o n , i n t i m a c y , and deeper s e l f - d i s c l o s u r e . I n an at tempt t o keep t h e t i m e frames e q u i v a l e n t and t o c o n t r o l f o r c o n t e n t l i t t l e o p p o r t u n i t y o r t i m e was p r o v i d e d f o r i n t e n s e i n v o l v e m e n t w i t h o t h e r s i n the c u r r e n t t r e a t m e n t program. W h i l e t h i s speaks t o a r e q u i r e m e n t f o r a h i g h e r degree o f t r e a t m e n t p o t e n c y i n g r o u p s , the work by A s c h (1952) , F e s t i n g e r and C a r l s m i t h (1959), Rokeach (1971) , 168 V i n o k u r (1971) and o t h e r s i n d i c a t e d t h a t a l a r g e group i n f l u e n c e e f f e c t can be expec ted w i t h l i t t l e a t t e n t i o n t o group f o r m a t i o n and development , and i n f a c t w i t h l i t t l e o r no p r i o r c o n t a c t . However, t h e r e remains the p o s s i b i l i t y t h a t t r e a t m e n t potency i s an i m p o r t a n t f a c t o r and s h o u l d be i n v e s t i g a t e d . The prob lem o f m a i n t a i n i n g a p a r a l l e l c o n t e n t i n b o t h a group and an i n d i v i d u a l format i n o r d e r t o c o n s t r u c t a m e a n i n g f u l c o n t r a s t would i n v a r i - a b l y become much more d i f f i c u l t t h a n i n the c u r r e n t s t u d y however. In o r d e r t o remedy t h i s s i t u a t i o n i t i s p o s s i b l e t o c o n s t r u c t s t r u c t u r e d group e x e r c i s e s such as t h o s e s u g g e s t e d by P f e i f f e r and Jones (1974) which would be m u t u a l l y a d a p t a b l e t o b o t h group and i n d i v i d u a l s e t - t i n g s , would enhance p e r s o n a l awareness i n each s e t - t i n g , and would i n a d d i t i o n enhance group c o h e s i o n and t r u s t i n the group c o n d i t i o n . A s e r i e s o f such e x e r - c i s e s would thus d e v e l o p the a t t r i b u t e s o f group t r e a t m e n t t h a t a r e h i g h l y v a l u e d by p r a c t i t i o n e r s and 169 t h e o r e t i c i a n s , and y e t a r e somewhat weak i n the p r e s e n t t r e a t m e n t . In examin ing what may have i n f l u e n c e d the outcome o f t h i s s t u d y i t i s q u i t e p o s s i b l e t h a t d i m e n s i o n s o f r e l e v a n t c o n t r a s t s between the f o r m a t s , the t h e r a p e u t i c components t h e m s e l v e s , have not been a c c u r a t e l y u n d e r - s t o o d o r c l e a r l y a r t i c u l a t e d w i t h i n the f i e l d w i t h t h e development o f a p p r o p r i a t e measures and e x p e r i m e n t a l c o n t r a s t s ( B l o c h e t . a l . , 1981, K l e i n , 1983) . The a c c u r a t e d e s c r i p t i o n o f these t h e r a p e u t i c components and the development o f measures f o r the components would r e q u i r e a r e t u r n t o a p r e - t h e o r e t i c a l p o s i t i o n o f p h e n o m e n o l o g i c a l l y i n v e s t i g a t i n g the formats and t h e r e b y g e n e r a t i n g f a c t o r s , r a t i o n a l e s , measures , and c r i t i c a l e x p e r i m e n t a l c o n t r a s t s . T h i s would be a h i g h l y d e s i r a b l e t a s k o f f u t u r e r e s e a r c h . A f o u r t h p o s s i b l e l i m i t a t i o n o f t h i s s t u d y r e f e r s t o the f a c t t h a t p r e - e x i s t i n g program g u i d e l i n e s r e q u i r e d t h e d i v e r s i o n o f about h a l f the a p p l i c a n t s t o the c u r r e n t program t o o t h e r a g e n c i e s . These g u i d e - l i n e s a r e e s s e n t i a l l y the same as t h o s e t h a t e x i s t i n 170 s i m i l a r c l i n i c s a c r o s s Nor th Amer ica and a r e d e s i g n e d t o d i r e c t the more s e r i o u s a l c o h o l - a d d i c t e d c l i e n t s and m e n t a l l y i l l c l i e n t s t o more a p p r o p r i a t e r e s o u r c e s . However t h e net e f f e c t o f t h i s s e l e c t i v i t y f a c t o r i s t h a t i t may not be i m p l i e d t h a t t h i s t r e a t m e n t program would be e f f e c t i v e i f i t were t o be used w i t h t h e s e a d d i c t e d o r m e n t a l l y i l l c l i e n t s . W h i l e t h e l i t e r a t u r e i s i n c o n s i s t e n t on t h i s p o i n t , Heather and R o b e r t s o n (1981) c o n c l u d e t h a t the c u r r e n t t y p e o f program i s a l s o e f f e c t i v e w i t h a l c o h o l a d d i c t s . The c u r r e n t problem d r i n k e r sample i s a l s o lower i n s e v e r i t y o f a l c o h o l consumption t h a n o t h e r samples used i n p r i o r r e s e a r c h on n o n - a d d i c t e d prob lem d r i n k - e r s . As a r e s u l t i t remains p o s s i b l e t h a t t h e program would be l e s s e f f e c t i v e w i t h more s e v e r e b u t n o n - a d d i c t e d problem d r i n k e r s . A r e p l i c a t i o n o f t h e c u r r e n t program w i t h more severe c l i e n t s may be r e - q u i r e d b e f o r e t h i s approach can be a c c e p t e d as w i d e l y a p p l i c a b l e . A f i f t h p o s s i b l e l i m i t a t i o n w i t h the c u r r e n t s t u d y was t h a t fewer c l i e n t s a p p l i e d f o r t h e program t h a n 171 were e x p e c t e d . A r e p l i c a t i o n o f t h i s s t u d y w i t h more s u b j e c t s would be advantageous i n t h a t s t a t i s t i c a l c o n t r a s t s would be more p o w e r f u l and s i g n i f i c a n t d i f f e r e n c e s c o u l d more e a s i l y emerge. A s i x t h p o s s i b l e l i m i t a t i o n r e f e r s t o t h e s i g n i f i - c a n t d i f f e r e n c e between the t e s t c o n d i t i o n s on t h e v a r i a b l e s o f r e l a t i o n s h i p , p r o v i d i n g s i g n i f i c a n t o t h e r s , and prob lem d u r a t i o n . W h i l e t h e s e were t h e o n l y s i g n i f i c a n t d i f f e r e n c e s found among the f o u r t e e n v a r i a b l e s c o n s i d e r e d , i t remains p o s s i b l e t h a t t h i s c r e a t e d a s y s t e m a t i c b i a s i n outcome. A sample w i t h no p r e - t e s t s i g n i f i c a n t d i f f e r e n c e s would c l e a r l y be more d e s i r a b l e . A s eventh p o s s i b l e l i m i t a t i o n o f t h e c u r r e n t s t u d y which must be acknowledged c o n c e r n s the change o f t h e p r o c e d u r e mid-way t h r o u g h the s t u d y due t o t h e l ower t h a n expec ted re sponse t o the r e q u e s t f o r s u b j e c t s . I t w i l l be r e c a l l e d t h a t the s u b j e c t s a w a i t i n g t r e a t m e n t were t h e n p l a c e d i n the w a i t - l i s t p r i o r t o p a r t i c i p a - t i o n i n t h e i r p r e - a s s i g n e d t r e a t m e n t c o n d i t i o n , so t h a t each o f the t r e a t m e n t c o n d i t i o n s and the w a i t - l i s t 172 c o n t r o l c o n d i t i o n c o u l d have the l a r g e s t a v a i l a b l e number o f s u b j e c t s . S u b j e c t s r e t u r n e d t o t h e i r p r e - a s s i g n e d treatment a f t e r the w a i t - l i s t p e r i o d r a t h e r t h a n b e i n g randomly a s s i g n e d t o each o f the two t r e a t m e n t c o n d i t i o n s s i n c e they had a l r e a d y been i n f o r m e d about t h e i r t rea tment c o n d i t i o n a t the f i r s t t e l e p h o n e c o n t a c t . Consequent ly i t was r e q u i r e d t h a t t h o s e s u b j e c t s who appeared i n b o t h the w a i t - l i s t and t h e t r e a t m e n t c o n d i t i o n s be removed from t h e d a t a p o o l o f one o f the c o n d i t i o n s f o r the purpose o f d a t a a n a l y s i s . T h i s was done so t h a t they would not be compared w i t h themse lves . S e v e r a l p o s s i b l e c r i t i c i s m s r e s u l t i n g from t h i s s t r a t e g y are c o n s i d e r e d . On the p o s i t i v e s i d e , i t a l l o w e d d a t a a n a l y s i s w i t h a l a r g e r s u b j e c t p o o l than would have o t h e r w i s e been t h e c a s e . T h i s enhances the r e p l i c a b i l i t y o f t h e r e s u l t s i n d e c r e a s i n g the chance e f f e c t o f a few p o s s i b l y u n i q u e l y d i f f e r e n t s u b j e c t s . A g r e a t e r s u b j e c t p o o l a l s o reduces the d i f f e r e n c e s r e q u i r e d 173 between the means o f the t r e a t m e n t c o n d i t i o n s f o r a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e t o be e s t a b l i s h e d . A r e l a t e d c r i t i c i s m o f t h e r e s e a r c h p r o c e d u r e i s t h a t the ass ignment o f o n l y some s u b j e c t s t o a w a i t - l i s t p r i o r t o t r e a t m e n t c o u l d i n t r o d u c e a s y s t e m a t i c b i a s t o t h i s subgroup which would then i n f l u e n c e outcomes. One p r o c e d u r e f o r a d d r e s s i n g t h i s i s t h a t w a i t - l i s t s u b j e c t s were not in formed t h a t t h e y were p l a c e d on a w a i t - l i s t c o n d i t i o n . Thus t h e i r own p e r c e p t i o n would have been t h a t t h e i r s i t u a t i o n was s i m i l a r t o t h a t o f o t h e r s around them. A second p r o c e d u r e t a k e n t o address t h i s p o s s i b i l i t y was t h a t the e x - w a i t - l i s t group was c o n t r a s t e d t o t h e o t h e r t r e a t m e n t s u b j e c t s t o i n v e s t i g a t e whether any d i f f e r - ences r e l a t e d t o b e i n g w a i t - l i s t e d emerged. As r e p o r t - ed i n the above d a t a a n a l y s e s i t appears t h a t a b i a s was not i n t r o d u c e d by p r i o r i n c l u s i o n i n t h e w a i t - l i s t . Another r e l a t e d p o s s i b l e c r i t i c i s m o r i g i n a t e s from the f a c t t h a t ass ignment t o the w a i t - l i s t c o n d i - t i o n was not random but r a t h e r was a p p l i e d t o a l l c l i e n t s a v a i l a b l e a t a p a r t i c u l a r d e c i s i o n - m a k i n g 174 p o i n t . A r e j o i n d e r t o t h i s c r i t i c i s m p r o p o s e s t h a t t h i s a c t i o n may not have v i o l a t e d the r e q u i r e m e n t s o f random ass ignment even though i t was u n u s u a l . T h i s r e j o i n d e r sugges t s t h a t s u b j e c t s randomly a s s i g n e d t o one c o n d i t i o n may be r e a s s i g n e d t o a n o t h e r c o n d i t i o n i f t h e v a r i a b l e s o f i n t e r e s t i n i n i t i a t i n g t h e random ass ignment i n the f i r s t p l a c e a r e not u t i l i z e d i n d e c i d i n g reas s ignment and the e x i s t e n c e o f p o s s i b l e s y s t e m a t i c d i f f e r e n c e s a r e i n v e s t i g a t e d a f t e r w a r d . An e i g h t h p o s s i b l e c r i t i c i s m o f the s t u d y i s t h a t c o m p l i a n c e w i t h each o f t h e homework ass ignments was no t a s s e s s e d . Had r e s o u r c e s been a v a i l a b l e , a measure o f c o m p l e t i o n o f each ass ignment would have been t a k e n . R e l a t e d t o t h i s i s a c r i t i c i s m o f the heavy r e l i a n c e i n t h i s s tudy o f s e l f - r e p o r t o f a l c o h o l c o n s u m p t i o n . D e s p i t e the s t r o n g s u p p o r t f o r t h i s method i n the l i t e r a t u r e , c o n c u r r e n t b l o o d t e s t o r b r e a t h a n a l y s i s would have been v e r y h e l p f u l . Thus a c r i t i c i s m can be o f f e r e d t h a t the t r e a t m e n t s u b j e c t s d i d no t reduce t h e i r consumpt ion but s i m p l y s t a t e d t h a t t h e y h a d . 175 I m p l i c a t i o n s o f t h i s S tudy f o r C o u n s e l l i n g Treatment Formats G i v e n t h e p r e v i o u s l y c i t e d l i m i t a t i o n s , any i m p l i c a t i o n s from t h i s r e s e a r c h must be c o n s i d e r e d t o be t e n t a t i v e . The c u r r e n t program was based l a r g e l y on a d e c i - s i o n making approach t o r e d u c i n g p r o b l e m a l c o h o l consumpt ion w i t h p a r t i c u l a r a t t e n t i o n t o t h e f u n c t i o n s o f p r o b l e m d r i n k i n g and t o b l o c k s t o d e c i s i o n - m a k i n g w i t h r e g a r d t o problem d r i n k i n g . The s u c c e s s o f t h i s program s u g g e s t s t h a t d e c i s i o n - m a k i n g i s a f r u i t f u l a p p r o a c h i n t r e a t m e n t . F u r t h e r r e s e a r c h would p r o v i d e an o p p o r t u n i t y t o t e s t the impact o f t h e d e c i s i o n - m a k - i n g components o f t h i s approach and i s s u g g e s t e d . T h u s , f o r c o u n s e l i n g t r e a t m e n t , one i m p l i c a t i o n i s t h a t group and i n d i v i d u a l formats a r e e q u a l l y e f f e c t i v e and t h u s group format may be chosen f o r many t r e a t m e n t needs . A second i m p l i c a t i o n i s t h a t a t r e a t m e n t program which used d e c i s i o n - m a k i n g as a c e n t r a l concept 176 p r o v e d t o have a p o s i t i v e e f f e c t i n r e d u c i n g a l c o h o l abuse and t h u s s h o u l d be e x p l o r e f u r t h e r . The purpose o f the c u r r e n t s t u d y was t o i n v e s t i - g a t e whether a group format was more e f f e c t i v e i n p r o d u c i n g p o s i t i v e t rea tment outcomes t h a n was an i n d i v i d u a l f o r m a t . The l i t e r a t u r e rev i ewed r e v e a l e d some m e t h o d o l o g i c a l d i f f i c u l t i e s w i t h p r e v i o u s group v e r s u s i n d i v i d u a l format c o n t r a s t s . In a d d i t i o n , t h e l i t e r a t u r e s u g g e s t s a g e n e r a l i m p l i c a t i o n o f e q u i v a l e n t i m p a c t s o f t h e two t rea tment f o r m a t s : group and i n d i v i d u a l . However the t h e o r e t i c a l l i t e r a t u r e r e g a r d - i n g group t r e a t m e n t s rev iewed and t h e e m p i r i c a l l i t e r a - t u r e from s o c i a l p s y c h o l o g y sugges ted t h a t group i n t e r v e n t i o n s would be more i m p a c t f u l t h a n i n d i v i d u a l i n t e r v e n t i o n s . A t r ea tment model known t o be e f f e c t i v e w i t h a s p e c i f i c t a r g e t , r e d u c i n g a l c o h o l consumpt ion , was chosen as b e i n g w e l l - s u i t e d t o t h i s c o n t r a s t . The c u r r e n t s tudy found t h a t b o t h group and i n d i v i d u a l t r e a t m e n t formats were e q u a l l y e f f e c t i v e . T h i s was t r u e on a number o f outcome v a r i a b l e s as w e l l as on t h e c e n t r a l dependent v a r i a b l e s o f a l c o h o l 177 c o n s u m p t i o n . I t i s t e n t a t i v e l y c o n c l u d e d from t h i s s t u d y t h a t the two approaches t o t r e a t m e n t , group and i n d i v i d u a l format , a r e o f e q u i v a l e n t impac t , i n terms o f p r o d u c i n g e q u a l l y s u c c e s s f u l and l a s t i n g outcomes, when c o n t e n t i s c o n t r o l l e d . T h i s c o n c l u s i o n i m p l i e s t h a t c l i n i c a l d e c i s i o n s o f whether o r not t o use group o r i n d i v i d u a l format may t h e n t u r n t o o t h e r c o n s i d e r a - t i o n s . I t remains p o s s i b l e t h a t d i f f e r e n t t y p e s o f i n d i v i d u a l s , o r d i f f e r e n t t y p e s o f problems a r e b e t t e r r e s p o n d e d t o by one format o r the o t h e r . F o r example, O r l i n s k y and Howard (1978) p o i n t out i n t h e i r rev i ew o f t h e group v e r s u s i n d i v i d u a l format r e s e a r c h " . . . i t s t i l l s seems p l a u s i b l e t h a t some s o r t s o f p a t i e n t s and some s o r t s o f p r o b l e m s , might be t r e a t e d more e f f e c - t i v e l y on an i n d i v i d u a l b a s i s , w h i l e f o r o t h e r s group t h e r a p y o f some k i n d would be the t rea tment o f c h o i c e ( p . 3 1 0 ) . " O t h e r c o n s i d e r a t i o n s r e l e v a n t t o t h e c h o i c e o f group o r i n d i v i d u a l format i n c l u d e economic f a c t o r s and e f f o r t s t o maximize the number o f c l i e n t s t h a t can be t r e a t e d w i t h t h e r e s o u r c e s a v a i l a b l e . T a k i n g t h e s e two 178 p o i n t s i n t o a c c o u n t i t i s suggested t h a t group format i s t h e format o f c h o i c e . The f i n d i n g o f a s i g n i f i c a n t d i f f e r e n c e i n outcome s c o r e s a s s o c i a t e d w i t h t rea tment as compared t o a w a i t - l i s t c o n t r o l c o n d i t i o n , compare f a v o r a b l y w i t h r e s u l t s o f p r e v i o u s s t r u c t u r e d t r e a t m e n t s i n t h i s a r e a ( e . g . M i l l e r & Munoz, 1982) . I m p l i c a t i o n s o f T h i s Study f o r F u t u r e R e s e a r c h As noted above , l i m i t a t i o n s i n t h i s s t u d y r e q u i r e t h a t a l l i m p l i c a t i o n s be c o n s i d e r e d t o be t e n t a t i v e . Based on t h e t h e o r e t i c a l l i t e r a t u r e on t r e a t m e n t groups i t was proposed t h a t a group format added s e v e r a l t h e r a p e u t i c f a c t o r s t h a t would be a b s e n t i n an i n d i v i d u a l f o r m a t . These were: i n t e r a c t i o n s , c o h e s i v e - n e s s , and v i c a r i o u s l e a r n i n g . The c u r r e n t s tudy does not s u p p o r t the h y p o t h e s i s t h a t a group f o r m a t , and thus t h e s e proposed f a c t o r s 179 gave a d d i t i o n a l impact t o a group i n t e r v e n t i o n o v e r an i n d i v i d u a l i n t e r v e n t i o n when c o n t e n t was h e l d c o n s t a n t . S e v e r a l p o s s i b i l i t i e s f o l l o w from t h i s r e s u l t . I t t e n t a t i v e l y appears t h a t t h e r e may be , a f t e r a l l , no g e n e r a l d i f f e r e n c e i n impact between group and i n d i v i d - u a l t r ea tment f o r m a t s . T h i s i s a most i m p o r t a n t c o n c l u s i o n t o be d e r i v e d from t h i s s t u d y . W h i l e t h i s outcome was unexpected and the r e s u l t s i n t h i s s t u d y must be h e l d t o be t e n t a t i v e g i v e n m e t h o d o l o g i c a l p r o b l e m s , i t i s c l e a r t h a t the s t r o n g e s t i m p l i c a t i o n s o f s o c i a l p s y c h o l o g y r e s e a r c h a r e c o n s i s t e n t w i t h t h e p r e s e n t a t i o n o f the c u r r e n t t r e a t m e n t i n s u p p o r t i n g t h a t t h i s s t u d y produced the n e c e s s a r y and s u f f i c i e n t c o n d i t i o n s f o r adequate i n t e r p e r s o n a l i n f l u e n c e . I t i s a l s o c l e a r t h a t the c o n t r o l o f t r e a t m e n t c o n t e n t a c r o s s formats i n t h i s s tudy was e x c e p t i o n a l l y s t r i n g e n t . T h u s , w h i l e m e t h o d o l o g i c a l , s t a t i s t i c a l o r s a m p l i n g s i z e o b j e c t i o n s can be r a i s e d and s u g g e s t i o n s f o r g r e a t e r power o r g r e a t e r c o n t r o l may be made, i t i s c o m p e l l i n g t o accept these r e s u l t s . T h i s i s p a r t i c u - l a r l y so i n the c o n t e x t o f p r e v i o u s l e s s w e l l - c o n t r o l l e d s t u d i e s which have , i n sum, come t o t h e same 180 c o n c l u s i o n . The p r e s e n t s tudy was c a r e f u l l y c o n s t r u c t - ed t o e x e r t more c o n t r o l over t h e p r e v i o u s l y most p r o b l e m a t i c v a r i a b l e o f group v e r s u s i n d i v i d u a l format c o n t r a s t s , t h a t o f t rea tment c o n t e n t . I t a p p e a r s t h a t when t h i s v a r i a b l e i s c o n t r o l l e d , outcome d i f f e r e n c e s between the formats do not emerge. T h i s c o n c l u s i o n must be t e n t a t i v e g i v e n the d i f f i c u l t i e s p r e s e n t i n the c u r r e n t s t u d y b u t i t i s t empt ing t o a c c e p t i t as a v a l i d h y p o t h e s i s worthy o f a l e s s p r o b l e m a t i c r e p l i c a - t i o n g i v e n t h a t i t i s i n agreement w i t h p r e v i o u s r e s e a r c h . I f t h e s e r e s u l t s can be r e p l i c a t e d , o t h e r r e s e a r c h c o n c e r n s 'then may come t o the f o r e , such as t h e n a t u r e o f the t h e r a p e u t i c components a t work i n each format and the p r o c e s s e s by which these formats o p e r a t e i n o r d e r t o c r e a t e a t h e r a p e u t i c i m p a c t . F u r t h e r r e s e a r c h c o u l d a l s o seek t o enhance the i n t e n s i t y o f t h e group and i n d i v i d u a l t h e r a p e u t i c e x p e r i e n c e w h i l e c o n t i n u i n g t o h o l d c o n t e n t c o n s t a n t . T h i s would be d i f f i c u l t but perhaps n o t a b s o l u t e l y i m p o s s i b l e . A d d i t i o n a l l y , r e s e a r c h c o u l d e x p l o r e the i n t e r a c t i o n o f s e l e c t e d i n d i v i d u a l d i f f e r e n c e s o f p e r s o n a l i t y , demograph ic , o r 181 p r o b l e m s e v e r i t y v a r i a b l e s w i t h t r e a t m e n t format t o i n d i c a t e o p t i m a l p lacement . S u g g e s t i o n s f o r F u t u r e R e s e a r c h S u g g e s t i o n s f o r f u t u r e r e s e a r c h i n c l u d e the f o l l o w i n g : 1. The t h e r a p e u t i c components as o u t l i n e d by Yalom (1975) and B l o c h e t a l . (1981) were f e l t t o be c o n c e p - t u a l l y l e s s t h a n s a t i s f a c t o r y i n t h e c o u r s e o f t h e c u r r e n t s t u d y . T h e r e a r e , f o r example , no i n d i c a t i o n s i f a l l t h e r a p e u t i c components p r o p o s e d by Yalom o c c u r i n a l l g r o u p s , i f a l l a r e e s s e n t i a l t o change, o r even i f t h e u n d e r s t a n d i n g o f the n a t u r e o f t h e f a c t o r s themse lves i s a c c u r a t e . In a d d i t i o n , few i n d i c a t i o n s a r e p r o v i d e d i n the r e s e a r c h l i t e r a t u r e , o t h e r t h a n some r e t r o s p e c t i v e s u r v e y s o f c l i e n t s u s i n g t h e Yalom q u e s t i o n n a i r e , as t o which f a c t o r s a r e most i m p o r t a n t i n what s i t u a t i o n s , o r even whether some f a c t o r s a r e i m p o r t a n t a t a l l . T h i s gap was f e l t t o be p a r t i c u l a r l y r e l e v a n t i n t h e c u r r e n t s t u d y when c o n s i d e r i n g t h e a p p a r e n t d i f f e r e n c e s i n a v a i l a b l e t h e r a p e u t i c f a c t o r s 182 i n the s e p a r a t e formats o f group and i n d i v i d u a l t r e a t - ment. I t appears t h a t the t h e r a p e u t i c f a c t o r s as c o n c e p t s grew out o f t h e o r e t i c a l work some y e a r s ago w h i c h was t h e n c o n v e r t e d t o a q u a n t i t a t i v e s c a l e by Y a l o m . However, i t i s u n c l e a r whether these t h e o r e t i - c a l c o n c e p t s a r e a c c u r a t e r e f l e c t i o n s o f the a c t u a l t h e r a p e u t i c mechanisms t h a t encourage p e r s o n a l change. I n r e v i e w i n g t h e r a p e u t i c f a c t o r s as proposed t o o c c u r i n group and i n d i v i d u a l i n t e r v e n t i o n s i t was c o n c l u d e d t h a t the two formats would d i f f e r o n l y on c o h e s i o n , i n t e r a c t i o n , and v i c a r i o u s l e a r n i n g , which were judged t o be p r e s e n t i n a group format but not p r e s e n t i n an i n d i v i d u a l f o r m a t . Thus i t i s sugges ted t h a t a p h e n o m e n o l o g i c a l a n a l y s i s o f t h e r a p e u t i c components be u n d e r t a k e n . I t i s f u r t h e r sugges ted t h a t t h i s be c a r r i e d o u t b o t h w i t h i n d i v i d u a l and group f o r m a t s . T h i s r e s e a r c h s h o u l d attempt t o d e v e l o p a model o f change and o f f a c t o r s which a s s i s t change which may be more a c c u r a t e , d e t a i l e d and r i c h e r t h e n p r e v i o u s s u g g e s t i o n s as i t would be based on a c t u a l o b s e r v a - t i o n s . These c o u l d then be used t o produce measures and e x p e r i m e n t a l c o n t r a s t s o f b o t h f a c t o r s and 183 a l t e r n a t i v e models o f change, i n o r d e r to enhance t h e r a p e u t i c impac t . 2. A r e p l i c a t i o n and e x t e n s i o n o f the c u r r e n t s t u d y i s recommended w i t h the f o l l o w i n g s e p a r a t e p u r p o s e s i n m i n d : ( i ) A r e p l i c a t i o n w i t h a s u b j e c t sample which e x h i b i t s a more s e v e r e l e v e l o f a l c o h o l consumpt ion p r o b l e m . F i r s t l y t h i s would p e r m i t the e f f i c a c y o f the c u r r e n t program t o be t e s t e d w i t h s u b j e c t s more t y p i c a l t o o t h e r programs reviewed above . Secondly t h i s would e l i m i n a t e the ' f l o o r e f f e c t ' sugges ted above as r e d u c - i n g the range o f p o s s i b l e change s i n c e s u b j e c t s i n the c u r r e n t s tudy had g e n e r a l l y lower consumption a t the o u t s e t o f the i n t e r v e n t i o n . ( i i ) A r e p l i c a t i o n w i t h more s u b j e c t s f o r g r e a t e r power o f the s t a t i s t i c a l c o n t r a s t s would i n c r e a s e the p o t e n t i a l s i g n i f i c a n c e o f d i f f e r e n c e s between the means o f the d i f f e r e n t t r e a t - ment c o n d i t i o n s . S e c o n d l y , w h i l e the a l t e r a t i o n o f the e x p e r i m e n t a l d e s i g n mid-way t h r o u g h the t r e a t m e n t was n o t c o n s i d e r e d t o be a " f a t a l " f l a w , i t was n o t , on t h e o t h e r hand , d e s i r a b l e . R e p l i c a t i o n wi thout t h i s d e s i g n change would add t o the s i g n i f i c a n c e o f the r e s e a r c h by i n c r e a s i n g the e l egance o f the e x p e r i m e n t a l d e s i g n . 184 T h i r d l y , a l a r g e r s tudy sample would be l e s s l i k e l y t o show s i g n i f i c a n t chance d i f f e r e n c e s a t p r e - t e s t such as r e l a t i o n s h i p , p r o v i s i o n o f a s i g n i f i c a n t o t h e r , and p r o b l e m d u r a t i o n , i n the c u r r e n t sample . ( i i i ) A r e p l i c a t i o n and e x t e n s i o n o f the c u r r e n t program u s i n g i n v o l v e m e n t - e n h a n c i n g t e c h n i q u e s t o t e s t whether i n c r e a s i n g involvement and i n t e n s i t y , f e a t u r e s o f t e n c i t e d as i m p o r t a n t by group t rea tment p r o p o n e n t s , c o u l d be r e l a t e d to an i n c r e a s e d a d d i t i o n a l impact t o the group f o r m a t . Methods f o r i n c r e a s i n g these f e a t u r e s a r e sugges ted above i n the p o s s i b l e development o f s t r u c t u r e d e x e r c i s e s such as those l i s t e d by P f e i f f e r and Jones (1974). A drawback o f t h i s r e s e a r c h sugges - t i o n i s t h a t the c o n t r o l o f c o n t e n t becomes much more d i f f i c u l t when the focus s h i f t s from a p s y c h o - e d u c a - t i o n a l format as u t i l i z e d i n the c u r r e n t s t u d y t o one dominated by the emerging p r o c e s s o f i n t e r a c t i o n s . 3 . A f u r t h e r r e s e a r c h s u g g e s t i o n i s t h a t t h e impact o f t h e d e c i s i o n - m a k i n g i n t e r v e n t i o n s used h e a v i l y i n t h e c u r r e n t s tudy be c o n t r a s t e d t o t h e more b a s i c a l c o h o l consumpt ion r e d u c t i o n s k i l l s t r a i n i n g i n c l u d e d i n t h i s program and the major i n t e r v e n t i o n o f many 185 p r e v i o u s programs . I t was proposed t h a t d e c i s i o n - m a k - i n g would add s i g n i f i c a n t l y t o the b a s i c t r e a t m e n t model but t h i s was u n t e s t e d by the p r e s e n t r e s e a r c h . F u r t h e r r e s e a r c h would a l s o d i r e c t l y a s s e s s t r e a t m e n t c o m p l i a n c e by measures r e l a t e d t o each o f t h e i n t e r v e n - t i o n s as w e l l as a s s e s s i n g a l c o h o l consumpt ion by b l o o d o r b r e a t h t e s t as w e l l as s e l f - r e p o r t . 4. A l a s t s u g g e s t i o n f o r f u t u r e r e s e a r c h r e f e r s t o t h e p o s s i b i l i t y t h a t each o f a group o r i n d i v i d u a l format may have been more i m p a c t f u l f o r d i f f e r e n t i n d i v i d u a l s , based perhaps on p e r s o n a l i t y , d e m o g r a p h i c , o r problem s e v e r i t y f e a t u r e s o f the p a r t i c i p a n t s . S e l e c t e d ' i n d i v i d u a l d i f f e r e n c e s c o u l d be c o n t r a s t e d w i t h format i n a r e s e a r c h d e s i g n t o e x p l o r e t h i s f u r t h e r . Summary The p r e s e n t s tudy sought t o c o n t r a s t group and i n d i v i d u a l t r e a t m e n t formats w h i l e r e s o l v i n g a p e r s i s - t e n t prob lem o f p r e v i o u s r e s e a r c h , t h a t o f h a v i n g w i d e l y d i f f e r e n t c o n t e n t s i n each t r e a t m e n t format ( o r , 186 t o a l e s s e r d e g r e e , d i f f e r e n t t r e a t m e n t l e n g t h s , t r e a t m e n t s e s s i o n s l e n g t h s , d i f f e r e n t t y p e s o f c l i e n t s , o r d i f f e r e n t t h e r a p i s t s i n each f o r m a t ) . The r e s u l t s o f t h i s s t u d y a r e t e n a t i v e g i v e n s e v e r a l major l i m i t a - t i o n s b u t sugges t t h a t t rea tment i s s u c c e s s f u l w i t h t h e t a r g e t p r o b l e m and w i t h the program u s e d , b u t t h a t n e i t h e r group nor i n d i v i d u a l t r e a t m e n t s a r e s u p e r i o r t o one a n o t h e r . 187 BIBLIOGRAPHY Adams, D. (1983). 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The M i c h i g a n A l c o h o l i s m S c r e e n i n g T e s t . A m e r i c a n J o u r n a l o f P s y c h i a t r y . 127. 12, 89-94 . S e l z e r , M. (1980). A l c o h o l i s m and a l c o h o l i c p s y c h o s i s . In H . K a p l a n , A . Freeman & B . Sadock ( E d s . ) , Comprehensive t e x t b o o k o f p s y c h i a t r y . (3rd E d . ) . B a l t i m o r e , MD: W a v e r l y . Shaw, M. (1985). Group dynamics : The p s y c h o l o g y o f s m a l l g r o u p . New Y o r k : McGraw H i l l . Shulman, L . (1979) . The S k i l l s o f H e l p i n g I n d i v i d u a l s and G r o u p s . I t a s c a , 1 1 1 . : Peacock . S o b e l l , L . & S o b e l l , M. (1977) . V a l i d i t y o f s e l f - r e p o r t s i n t h r e e p o p u l a t i o n s o f a l c o h o l i c s . J o u r n a l o f C o u n s e l l i n g and ' C l i n i c a l P s y c h o l o g y . 46, 901-907. Solomon, S. & H a r f o r d , T . (1984) . D r i n k i n g norm v e r s u s d r i n k i n g b e h a v i o r . A l c o h o l i s m : C l i n i c a l and E x p e r i m e n - t a l R e s e a r c h . 8, 5 ,460-466 . S t r o n g , S. (1978). S o c i a l p s y c h o l o g i c a l a p p r o a c h t o p s y c h o t h e r a p y r e s e a r c h . In S o l G a r f i e l d & A l l e n B e r g i n ( E d s . ) , Handbook o f p s y c h o t h e r a p y and b e h a v i o r change . (2nd E d . ) . New Y o r k : W i l e y . T a n f o r d , S. & Penrod , S. (1984) S o c i a l i n f l u e n c e mode l : a f o r m a l i n t e g r a t i o n o f r e s e a r c h on m a j o r i t y and m i n o r i t y i n f l u e n c e p r o c e s s e s . P s y c h o l o g i c a l B u l l e t i n . 95, 2, 189-225. T e g e r , A . & P r u i t t , D. (1967) . Components o f group r i s k t a k i n g . J o u r n a l o f E x p e r i m e n t a l S o c i a l P s y c h o l o g y . 3, 189-205. 198 T h a r p , R. & W e t z e l , R. (1969) . B e h a v i o u r M o d i f i c a t i o n s i n the N a t u r a l Env ironment . New Y o r k : Academic P r e s s . T r i c e , H . & Roman, P. (1970) . D e l a b e l i n g , r e l a b e l i n g and A l c o h o l i c s Anonymous. S o c i a l Prob lems . 17, 538-546. T u r n e r , J . (1985) . S o c i a l c a t e g o r i z a t i o n and the s e l f - c o n c e p t : A s o c i a l c o g n i t i v e t h e o r y o f group b e h a v i o r . Advances i n Group P r o c e s s e s . 2, 77-121. T u r n e r , J . & Oakes , P . (1986) . The s i g n i f i c a n c e o f the s o c i a l i d e n t i t y concept f o r s o c i a l p s y c h o l o g y w i t h r e f e r e n c e t o i n d i v i d u a l i s m , i n t e r a c t i o n i s m , and s o c i a l i n f l u e n c e . B r i t i s h J o u r n a l o f S o c i a l P s y c h o l o g y . 25, 237-252. V i n o k u r , A . (1971). Review and t h e o r e t i c a l a n a l y s i s o f t h e e f f e c t o f group p r o c e s s e s upon i n d i v i d u a l and group d e c i s i o n s i n v o l v i n g r i s k . P s y c h o l o g i c a l B u l l e t i n , 4, 231-251. V o g l e r , R . E . , Weissbach , T . A . , Compton, J . V . & M a r t i n , G . T . (1977) . I n t e g r a t e d b e h a v i o u r change t e c h n i q u e f o r p r o b l e m d r i n k e r s i n t h e community. J o u r n a l o f C o n s u l t - i n g and C l i n i c a l P s y c h o l o g y . 45, 267-279. W a l l a c h , ,M. & Kogan, N . (1964) . R i s k t a k i n g : A s tudy i n c o g n i t i o n and p e r s o n a l i t y . New Y o r k : H o l t , R i n e h a r t , W i n s t o n . W a l l a c h , M & Kogan, N . (1965) . Group r i s k t a k i n g . J o u r n a l o f E x p e r i m e n t a l S o c i a l P s y c h o l o g y . 1, 1-19. Watson, C . , T i l l e s k j o r , C . , Hoodecheck-Schow, E . , P u c e l , J . Y . J a c o b s , L . (1984). Do a l c o h o l i c s g i v e v a l i d s e l f - r e p o r t s ? J o u r n a l o f S t u d i e s on A l c o h o l . 45, 344-348. Watson , C . (1985) . More reasons f o r a morator ium - a r e p l y t o M a i s t o and O ' F a r r e l l . J o u r n a l o f S t u d i e s on A l c o h o l , 46 . 5, 450-453. W i l l e m s , E . & C l a r k , R. (1969) . Dependence o f the r i s k y s h i f t on i n s t r u c t i o n s : A r e p l i c a t i o n . P s y c h o l o g i c a l R e p o r t s . 25, 811-814. W i l l i a m s , G . , A i t k e n , S. & M a l i n , H . (1985) . R e l i a b i l i t y o f 199 s e l f - r e p o r t e d a l c o h o l consumption i n a g e n e r a l p o p u l a - t i o n s u r v e y . J o u r n a l o f S t u d i e s on A l c o h o l . 46, 3, 223-227. Ya lom, I . (1975) . The T h e o r y and P r a c t i c e o f Group P s y c h o - t h e r a p y . New Y o r k : B a s i c Books. Z a j o n c , R. (1980) . Comprescence. In P . P a u l u s ( E d . ) , P s y c h o l o g y o f group p r o c e s s e s . New J e r s e y : Lawrence E r l b a u m . Z imbardo , P . , E b b e s e n , E . & M a s l a c h , C . (1977) . I n f l u e n c i n g a t t i t u d e s and chang ing b e h a v i o r s . (2nd E d . ) . R e a d i n g , MA: A d d i s o n - W e s l e y . 200 APPENDIX A SKILLS CONTROLLED DRINKING PROGRAM Date Dear D o c t o r : has a p p l i e d t o e n t e r t h e SKILLS d r i n k i n g Program of the Vancouver H e a l t h Department . The o b j e c t i v e o f t h i s program i s t o h e l p c l i e n t s a c h i e v e c o n t r o l o f t h e i r a l c o h o l c o n s u m p t i o n . C o n t r o l i s d e f i n e d as a maximum o f 3 d r i n k u n i t s (one d r i n k u n i t i s e q u i v a l e n t t o f o u r ounces o f wine f o r example) p e r day w i t h a t l e a s t two days o f a b s t i n e n c e p e r week, and no i n t e r f e r e n c e w i t h d a i l y f u n c t i o n i n g . In most cases c l i e n t s i n the c o n t r o l l e d d r i n k i n g program choose t o c o n t i n u e d r i n k i n g a l c o h o l though i n moderate amounts. I t i s t h e r e f o r e v e r y i m p o r t a n t t o i d e n t i f y c l i e n t s who f o r h e a l t h r e a s o n s h o u l d no t d r i n k a t a l l . We a r e a s k i n g f o r your h e l p . The accompanying "medica l c l e a r a n c e " form i s d e s i g n e d t o p r o v i d e us w i t h the m e d i c a l i n f o r m a t i o n we need t o c o u n s e l c l i e n t s a p p r o p r i a t e l y . C l i e n t s can be a c c e p t e d i n t o t h e program o n l y i f t h i s i n f o r m a t i o n i s p r o v i d e d by t h e i r d o c t o r . An i n f o r m a t i o n shee t r e g a r d i n g the m e d i c a l c o n d i t i o n s o f p a r t i c u l a r c o n c e r n i n t h o s e who consume a l c o h o l i s a l s o p r o v i d e d f o r y o u r c o n v e n i e n c e . Thank you f o r your h e l p . I f you wish t o d i s c u s s any a s p e c t o f the program p l e a s e f e e l f r e e t o c o n t a c t one o f u s . S. M a r i o n , M . D . Doug Adams M e d i c a l C o n s u l t a n t C o - O r d i n a t o r / S u p e r v i s o r 201 MEDICAL CLEARANCE STATEMENT Name o f C l i e n t The above c l i e n t has been e v a l u a t e d by me on (date) w i t h r e g a r d t o m e d i c a l c o n d i t i o n s t h a t may be c a u s e d o r e x a c e r b a t e d by a l c o h o l , p a r t i c u l a r l y t h o s e ment ioned on t h e accompanying i n f o r m a t i o n sheet and w i t h r e g a r d t o m e d i c a t i o n s t h a t may i n t e r a c t a d v e r s e l y w i t h a l c o h o l . In my o p i n i o n t h i s c l i e n t (check one or more as a p p r o p r i a t e ) ( ) has no m e d i c a l c o n d i t i o n caused o r e x a c e r b a t e d by a l c o h o l and i s t a k i n g no m e d i c a t i o n t h a t i n t e r a c t s a d v e r s e l y w i t h a l c o h o l ( ) has a r e l a t i v e c o n t r a i n d i c a t i o n t o a l c o h o l due t o t h e f o l l o w i n g m e d i c a l c o n d i t i o n ( s ) o r due t o the f o l l o w i n g m e d i c a t i o n ( s ) which he i s t a k i n g (name & dose) CNS D e p r e s s a n t s : A n t i h y p e r t e n s i v e s : A n t i - C o a g u l a n t s : NSAIDS o r s a l i c y l a t e s : A n t i - d i a b e t i c : O t h e r : However h e / s h e may consume a l c o h o l i n m o d e r a t i o n w i t h i n t h e f o l l o w i n g r e s t r i c t i o n ( ) has an a b s o l u t e c o n t r a i n d i c a t i o n t o a l c o h o l c o n s u m p t i o n and s h o u l d not d r i n k a l c o h o l a t a l l because To my knowledge t h e r e are no o t h e r m e d i c a l c o n d i t i o n s p r e s e n t and no o t h e r m e d i c a t i o n s b e i n g taken t h a t a r e r e l e v a n t t o d e t e r m i n i n g s a f e l e v e l s o f a l c o h o l consumpt ion f o r t h i s c l i e n t . Name o f P h y s i c i a n A d d r e s s S i g n a t u r e Date SKILLS CONTROLLED DRINKING PROGRAM VANCOUVER HEALTH DEPARTMENT 2*02 M e d i c a l C o n d i t i o n s and M e d i c a t i o n s o f C o n c e r n i n those who Consume A l c o h o l C e n t r a l Nervous System: b l a c k o u t s , c e r e b e l l a r a t a x i a , m i g r a i n e P e r i p h e r a l Nervous System: P e r i p h e r a l n e u r o p h a t h y 4 N e u r o l o g i c a l C o n d i t i o n s : E n d o c r i n e / m e t a b o l i c System: d i a b e t e s m e l l i t u s h i s t o r y o f a l c o h o l - r e l a t e d myopathy R e s p i r a t o r y System: C a r d i o v a s c u l a r System: G a s t r o - i n t e s t i n a l System: M u s c u l o s k e l e t a l System: P s y c h o l o g i c a l System: M e d i c a t i o n s : s e v e r e l y compromised r e s p i r a t o r y f u n c t i o n (wi th r i s k o f r e s p i r a t o r y f a i l u r e ) a r r h y t h m i a s , h y p e r t e n s i o n 2 a l c o h o l i c c i r r h o s i s , h i s t o r y o f s e v e r e a c u t e a l c o h o l i c l i v e r d i s e a s e , o t h e r c h r o n i c l i v e r d i s e a s e , p e p t i c u l c e r d i s e a s e g a s t r i t i s , m a l n u t r i t i o n , h i s t o r y o f p a n c r e a t i t i s d e p r e s s i o n , p e r s o n a l i t y change o r marked b e h a v i o u r a l changes w i t h a l c o h o l c o n s u m p t i o n p s y c h o s i s s e d a t i v e s o r m e d i c a t i o n s h a v i n g s e d a t i o n as a s i d e - e f f e c t , a n t i c o a g u l e n t s , b e t a b l o c k e r s , c e p h a l o s p o r i n s , d i s u l f i r a m , h y p o g l y c e m i c s , m e t r o n i d a z o l e , n o n s t e r o i d a l a n t i - i n f l a m m a t o r y d r u g s , a n t i c o n v u l s a n t s , s a l i c y l a t e s NOTES: 1) T h i s l i s t i s no t i n t e n d e d t o be e x h a u s t i v e 2) M a j o r p h y s i c a l d i s a b i l i t y due t o p a s t a l c o h o l consumpt ion i s g e n e r a l l y an a b s o l u t e c o n t r a i n - d i c a t i o n t o a l c o h o l consumpt ion SKILLS CONTROLLED DRINKING PROGRAM VANCOUVER HEALTH DEPARTMENT 2CT3 APPENDIX B WORRIED ABOUT YQUR PRINKING? The Vancouver Health Department offers an experimental controlled drinking program for those beginning to experience alcohol related prob-lems. If you wish to develop a healthier lifestyle and reduced use of alcohol - and speak to a program counsellor. If the program is suitable for you, 12 sessions can be arranged free of charge. Day or evening times are available. A l l enquiries are confi-dential . 204 APPENDIX C CONTROLLED DRINKING PROGRAM CONSENT FORM I am aware that the experimental Controlled Drinking Program is run as part of the Prevention Program in the Vancouver Health Department. The program involves new treatment techniques currently undergoing development. The purposes of the present program are to assess the treatment methods and to assist participants in reducing and controlling their use of alcohol. I understand that SKILLS i s a self-management program and that the client is responsible for using the techniques which the program offers. As there i s an ongoing evaluation of this program, the client agrees to f i l l out questionnaires and participate in follow-up. Time required for meetings and questionnaires will likely amount to 1 1/4 hours on 8 occa-sions. I understand that the program or those working in the program are not responsible i f the client is involved in a driving accident or any other personal or legal problems arising from drinking. The program is free and no consultant will accept a fee. If at any time a client feels that participation in the program is not helpful he or she may withdraw without any cost or loss of availability of other Vancouver Health Department services. Decisions to withdraw should be dis-cussed with the counsellor. Client Signature Witness: Counsellor Signature: Date: CITY OF VANCOUVER HEALTH DEPARTMENT 205 APPENDIX D The V a l i d i t y o f S e l f - R e p o r t Data As w i t h much o f the r e s e a r c h on c o n t r o l l e d d r i n k - i n g , the use o f s e l f - r e p o r t d a t a from c l i e n t s on a l c o h o l consumpt ion has been a f f e c t e d by l a y p e r c e p - t i o n s and the common assumption o f the d i s e a s e model s c h o o l o f thought , o f t e n as espoused t h rou gh A l c o h o l i c s Anonymous. One o f the c o n t e n t i o n s o f t h i s model i s t h a t p e o p l e w i t h d r i n k i n g problems w i l l m i n i m i z e and deny t h e i r d r i n k i n g consumpt ion . T h i s i s drawn from the c o n j e c t u r e s on the development o f the ' d i s e a s e ' and i s a model which has remained more o r l e s s u n t e s t e d u n t i l r e c e n t l y . However, i t has g a i n e d a g r e a t d e a l o f b e l i e f i n i t s t r u t h f u l n e s s , p a r t i c u l a r l y by p r o f e s s i o n - a l s t r a i n e d i n the t r a d i t i o n a l p e r s p e c t i v e s and i n t e r - v e n t i o n s i n a l c o h o l prob lems , and by c l i e n t s o f t r a d i - t i o n a l methods by p r o f e s s i o n a l s o r by s e l f - h e l p g r o u p s . I t has r e a c h e d a l e v e l where i t i s p e r c e i v e d as i n t e - g r a l t o t h e t r a d i t i o n a l a l c o h o l t r e a t m e n t model . Due 206 t o t h i s , c o n t r a r y e v i d e n c e may be p e r c e i v e d as e i t h e r a s p e c i a l case o r m i s t a k e n , and o n l y s u p p o r t i n g e v i d e n c e may be e a s i l y acknowledged. In the s h o r t r e v i e w below t h e p r i m a r y focus w i l l be on e x p l o r i n g the v a l i d i t y o f s e l f - r e p o r t d a t a . Midanek (1982) sugges ts t h a t the d e n i a l h y p o t h e - s i s , t h a t problem d r i n k e r s w i l l l i e and c o n c e a l t h e i r c o n s u m p t i o n , i s w i t h o u t an adequate e m p i r i c a l base and t h a t i t l e a d s t o a tendency t o d i s c r e d i t o r o b s c u r e c o n t r a d i c t o r y d a t a . She notes two outcomes from t h e d e n i a l h y p o t h e s i s o f d i s c r e p a n c i e s i n d r i n k i n g r e p o r t s by c o l l a t e r a l and problems d r i n k e r s : (1) i f the c o l l a t - e r a l r e p o r t i s h i g h e r i t i s taken as t h e more v a l i d and t h e a l c o h o l i c i s c o n s i d e r e d t o be a " d e n i e r . " The v e r a c i t y o f the c o l l a t e r a l r e p o r t i s u n q u e s t i o n e d . Or (2) i f the c o l l a t e r a l r e p o r t s lower consumpt ion t h a n t h e prob lem d r i n k e r , the c o l l a t e r a l l o s e s c r e d i b i l i t y and the l e s s e r r e p o r t e d amount i s a t t r i b u t e d t o l a c k o f c o n t a c t , f o r example w i t h i n a d r i n k i n g e n v i r o n m e n t , o r t h e a l c o h o l i c i s c o n s i d e r e d t o be c a r r y i n g out ' h i d d e n ' o r ' c o n c e a l e d ' d r i n k i n g . 207 " T h i s inves tment i n the ' d e n i a l ' e x p l a n a t i o n i s so s t r o n g t h a t even when one i s f a c e d w i t h c o n t r a d i c t o r y e v i d e n c e . . . t h e p r e f e r r e d r e s o l u t i o n i s t o somehow d i savow t h e c r i t e r i a ; as though the ends d e f i n e t h e means." (p.377) Cook (1985) touches on the t e n a c i t y w i t h w h i c h t h e d e n i a l h y p o t h e s i s and o t h e r b e l i e f s a r e h e l d i n t h e f a c e o f c o n t r a d i c t o r y e v i d e n c e . Cook notes t h a t p r o p o n e n t s o f t r a d i t i o n a l t r e a t m e n t and b e l i e f s i n a l c o h o l problem t r e a t m e n t a r e r e f l e c t i n g a c o n s i d e r a b l y d i f f e r e n t t r a i n i n g and method o f u n d e r s t a n d i n g t h a n t h a t used by b e h a v i o r a l r e s e a r c h e r s . D i f f e r e n t i a t i n g t h e s e b y ' t h e terms ' c r a f t s m a n ' and ' p r o f e s s i o n a l ' Cook p o i n t s out t h a t t h e e d u c a t i o n o f the c r a f t s m a n i s an i n d o c t r i n a t i o n t o t h e v i e w p o i n t o f a master c r a f t s m a n and the g o a l i s t o l e a r n t o t h i n k and a c t as do t h e i r m e n t o r s . C i t i n g K a l b and Propper i n 1976, he no te s t h a t adherence t o t r a d i t i o n a l c o n c e p t s , r e s i s t a n c e t o a l t e r n a t i v e v i e w p o i n t s , and r e f u s a l t o q u e s t i o n t h e i r own premises when c o n t r a d i c t o r y e v i d e n c e appear c r e a t e s an i n t e n s e l o y a l t y and u n i t y . These t r a d i t i o n a l c o n c e p t s a r e e x e m p l i f i e d by a t t i t u d e s such as 208 " . . . a l c o h o l i s m i s a d i s e a s e t h a t cannot be c u r e d , t h a t i t i s e s s e n t i a l l y something one i s r a t h e r t h a n some- t h i n g one has , and t h a t the o n l y way t o a v o i d t h e prob lems and symptoms o f b e i n g an a l c o h o l i c i s t o a b s t a i n from d r i n k i n g a l c o h o l t o t a l l y . D r i n k i n g , by d e f i n i t i o n , cannot be c o n t r o l l e d by a l c o h o l i c s (Cook, 1985, p . 4 4 ) . " T h i s c ra f t sman "knows" t h i s t o be t r u e t h r o u g h t h e f o l l o w i n g r o u t e . "One s i m p l y o b s e r v e s a l c o h o l i c d r i n k e r s o v e r a p e r i o d o f t i m e , and i t becomes o b v i o u s t h a t they c a n ' t c o n t r o l t h e i r d r i n k i n g u n l e s s they permanent ly and t o t a l l y a b s t a i n . G e t t i n g them t o a b s t a i n i s i n l a r g e p a r t a m a t t e r o f c o n v i n c i n g them t h a t they have an i n c u r a b l e d i s e a s e t h a t can be c o n t r o l l e d o n l y t h r o u g h t o t a l a b s t i n e n c e " ( p . 4 4 0 ) . Opposed t o t h i s on a lmost e v e r y l e v e l i s the b e h a v i o r a l s c i e n t i s t who i s t a u g h t t o query a l l p r e m i s e s and i s t a u g h t m u l t i p l e c o n t r a d i c t o r y v i e w p o i n t s . T h i s p r o f e s - s i o n a l i s a l s o t a u g h t t o g a t h e r e v i d e n c e and t e s t p r e m i s e s , and t o r e l y on t h e r e s u l t s o f t h e s e t e s t s t o a d j u s t and modi fy p r e m i s e s . The c r a f t s m a n i s c o n c e r n e d w i t h t h e i n d i v i d u a l a l c o h o l i c and i s d i smayed and m i s t r u s t f u l when p r e s e n t e d w i t h group d a t a and s t a t i s - t i c s from the p r o f e s s i o n a l which o b s c u r e s t h e 209 u n i q u e n e s s o f t h e i n d i v i d u a l case b u t i s p r e s e n t e d , a t l e a s t i n p a r t , t o make some s ta tements u s e f u l t o the i n d i v i d u a l case by the b e h a v i o r a l s c i e n t i s t . There has been a p r o t r a c t e d d i s c u s s i o n i n the l i t e r a t u r e around t h e v a l i d i t y o f c l i e n t ' s s e l f - r e p o r t o f d r i n k i n g d a t a . W h i l e t h i s i s an i s s u e w i t h any t y p e o f b e h a v i o r a l s e l f - r e p o r t , i t has been p a r t i c u l a r l y c o n t e n t i o u s w i t h a l c o h o l problems due t o the c u r r e n t d i s e a s e model and on J e l l i n e k ' s gamma a l c o h o l i c c l a s s i - f i c a t i o n as a r t i c u l a t e d i n media and by A l c o h o l i c s Anonymous f o l l o w e r s . B r i e f l y the model s t a t e s t h a t " . . . t h e a l c o h o l i c i s seen as a d e n i e r who w i l l m i n i m i z e h i s / h e r r e p o r t s o f consumpt ion and problems a s s o c i a t e d w i t h a l c o h o l . " (Midanek, 1982, p.358) T h a t i s , he o r she w i l l m i n i m i z e and deny the p r o b l e m , and must be e x p e c t e d t o l i e about the amount o f d r i n k i n g . The model i s i n c o n s i s t e n t i n t h a t i t a c c e p t s as t r u t h when h i g h p r o b l e m consumpt ion i s r e p o r t e d o r when a b s t i n e n c e i s r e p o r t e d c o n s i s t e n t l y . L e a r n i n g t h e o r y , on the o t h e r h a n d , a c c e p t s c o m p l i a n c e , such as a c c u r a t e s e l f - r e p o r t i n g , as an i s s u e t o be s p e c i f i c a l l y a d - d r e s s e d b u t not one t h a t i s i n s u r m o u n t a b l e . 210 The second Rand r e p o r t ( P o l i c h e t a l . , 1980, P o l i c h , 1982) a s s e s s e d the v a l i d i t y o f s e l f - r e p o r t s o f a l c o h o l consumpt ion i n perhaps the most r i g o r o u s assessment t o d a t e t o s p e c i f i c a l l y address t h i s c o n t e n - t i o u s p r o b l e m . They randomly and w i t h o u t w a r n i n g s e l e c t e d a s u b s e t (n=632) o f t h e i r f o l l o w - u p i n t e r v i e w s and asked f o r s e l f - r e p o r t , c o l l a t e r a l i n t e r v i e w , and c o n c u r r e n t p h y s i o l o g i c a l assessment , r e p o r t e d l y s e n s i - t i v e enough t o a s c e r t a i n approx imate consumpt ion l e v e l s f o r the p r e v i o u s day . O v e r a l l , t h e y found a s m a l l amount o f u n d e r - r e p o r t i n g b u t t h a t t h i s was s t a n d a r d a c r o s s a l l i n t e n s i t i e s o f d r i n k i n g and was n o t found t o be s i g n i f i c a n t l y h i g h e r among the more i n t e n s e d r i n k - e r s . P o l i c h (1982) b r i e f l y rev i ewed p r e v i o u s s t u d i e s , p o i n t i n g out t h a t these i n d i c a t e d t h a t " . . . s e l f - r e p o r t s o f c o n c r e t e d r i n k i n g problems a r e no t b i a s e d . In f a c t , t h e number o f o v e r - r e p o r t s f r e q u e n t l y e q u a l s o r exceeds t h e number o f u n d e r - r e p o r t s " ( p . 1 3 1 ) . R e g a r d i n g P o l i c h ' s own s t u d y , a f o u r y e a r f o l l o w - u p o f t r e a t e d i n d i v i d u a l s , P o l i c h c o n c l u d e s t h a t " . . . s e l f - r e p o r t s o f c o n c r e t e d r i n k i n g problems a r e g e n e r a l l y v a l i d . . . " (p.131) and t h a t outcome c l a s s i f i c a t i o n was " . . . n o t s u b s t a n t i a l l y a f f e c t e d by e r r o r s i n consumpt ion 211 r e p o r t s . . . " (p.123) and f u r t h e r recommends m u l t i p l e outcome measures . He a l s o notes a h i g h e r e r r o r r a t e f o r c o l l a t e r a l r e p o r t s t h a n f o r s e l f - r e p o r t s and t h a t t h e e x - p a t i e n t s were o v e r a l l " . . . m o r e l i k e l y t o r e p o r t symptoms and o t h e r t y p e s o f a l c o h o l problems" ( p . 1 3 1 ) . M i l l e r ( M i l l e r & Baca , 1983, M i l l e r , H e d r i c k , & T a y l o r , 1983) has u t i l i z e d b r e a t h t e s t s , b l o o d t e s t s , and c o l l a t e r a l i n t e r v i e w , i n d i c a t i n g o n l y t h a t t h e r e s u l t s c o n f i r m e d s e l f - r e p o r t s . S a n c h e z - C r a i g ( S a n c h e z - C r a i g & L e i , 1986) r e p o r t s u s i n g n e u r o p s y c h o l o g i c a l t e s t i n g , gamma-glutamyl t r a n s p e p t i d a s e b l o o d t e s t s , and c o l l a t e r a l r e p o r t s , i n d i c a t i n g t h a t these v a l i d a t e d s e l f - r e p o r t s . O r f o r d and K e d d i e (1986) used c o l l a t e r a l i n f o r m a t i o n a v a i l a b l e f o r 32 o f t h e i r 46 c l i e n t s and found i t t o be i n h i g h agreement w i t h s e l f - r e p o r t a l t h o u g h s e l f - r e p o r t t e n d e d t o be somewhat more s e v e r e and t h a t t h e r e were " . . . no i n s t a n c e s o f o u t r i g h t , u n r e s o l v e d d i sagreement between c o l l a t e r a l and c l i e n t accounts" ( p . 5 0 0 ) . V o g l e r (1977) found s e l f - r e p o r t s v a l i d a t e d by c o l l a t e r a l i n f o r m a t i o n , f i n d i n g v e r y h i g h concordance r a t e s , as 212 d i d G e r a r d and Saenger (1966) and E l a l - L a w r e n c e e t a l . (1987). M a i s t o , S o b e l l , & S o b e l l (1979) c o n t r a s t e d s e l f and c o l l a t e r a l r e p o r t s and found them t o be h i g h l y c o r r e l a t e d ( a l l beyond p< .01 . They c o n c l u d e d t h a t s e l f - r e p o r t s a r e g e n e r a l l y a r e l i a b l e s o u r c e o f d r i n k - i n g i n f o r m a t i o n . M a i s t o e t a l . (1982) found a h i g h c o n s i s t e n c y between s u b j e c t and c o l l a t e r a l r e p o r t s o f p o s t t r ea tment d r i n k i n g . Midanek (1982) rev iewed much o f the l i t e r a t u r e c o n c e r n i n g t h e v a l i d i t y o f s e l f - r e p o r t s o f d r i n k i n g b e h a v i o r . ' In c o n t r a s t w i t h b r e a t h and b l o o d t e s t s she found t h a t s e l f - r e p o r t i s g e n e r a l l y a c c u r a t e w i t h a common and c o n s i s t e n t t endency toward a low l e v e l o f u n d e r - r e p o r t i n g , and a s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n o f c o l l a t e r a l and s e l f - r e p o r t was g e n e r a l l y f o u n d . Leonard e t a l . (1983) a s s e s s e d c o l l a t e r a l a g r e e - ment not on c o n c r e t e d r i n k i n g b e h a v i o r s b u t on a g e n e r a l assessment d e v i c e f o r d i a g n o s i n g d r i n k i n g p r o b l e m s ; the M i c h i g a n A l c o h o l i s m S c r e e n i n g T e s t . 213 R e s u l t s o f c o l l a t e r a l and s e l f - r e p o r t were found t o be c o r r e l a t e d s i g n i f i c a n t l y w i t h each o t h e r (p<.01) w i t h , a l s o , a s i g n i f i c a n t tendency f o r t h e s e l f t o u n d e r - r e p o r t symptoms t o a t l e a s t some degree i n c o n t r a s t t o c o l l a t e r a l s (p< .05) . Leonard e t a l . c o n c l u d e t h a t t h e r e i s " . . . g e n e r a l s u p p o r t f o r t h e v a l i d i t y o f s e l f - r e p o r t s by a l c o h o l i c s . " (p.373) Disagreement was found t o be s y s t e m a t i c i n u n d e r - r e p o r t i n g o n l y on a l c o h o l prob lem i tems on the MAST and not s y s t e m a t i c on h e l p - s e e k i n g , l e g a l s o c i a l and work p r o b l e m s , o r m a r i t a l prob lem i t e m s . W i l l i a m s e t a l . (1985) rev iewed l i t e r a t u r e on r e l i a b i l i t y w i t h s e v e r a l p o p u l a t i o n s and found t h a t w i t h prob lem d r i n k e r s " . . . s a t i s f a c t o r y l e v e l s o f r e l i a b i l i t y o r v a l i d i t y on s e l f - r e p o r t e d consumpt ion m e a s u r e s . . . " (p.223) were found. W h i l e the a u t h o r ' s c e n t r a l purpose was t o p r o v i d e r e l i a b i l i t y on a g e n e r a l p o p u l a t i o n s u r v e y d e v i c e (us ing a sample o f 1395) , t h e y r e p o r t e d c o n t r a s t s o f measures t h a t a r e u s e f u l t o t h e c u r r e n t d i s c u s s i o n . They found t h e measure r e l i a b l e i n t h a t consumpt ion a t b a s e l i n e was s t r o n g l y r e l a t e d t o consumpt ion a t a f o u r t e e n and a t w e n t y - e i g h t day 214 r e t e s t . C o n c u r r e n t v a l i d i t y was a s s e s s e d by c o n t r a s t o f t h e t a r g e t measure, a r e c a l l measure , w i t h the e x t e r n a l c r i t e r i a o f a d a i l y d r i n k d i a r y and averaged a t a c o r r e l a t i o n o f r= .80 , a l t h o u g h t h i s was somewhat l ower w i t h r e f e r e n c e t o beer consumpt ion a l o n e among t h e t h r e e beverage a l c o h o l p r o d u c t s a s s e s s e d . P r e d i c - t i v e v a l i d i t y was a s se s sed on t e s t - r e t e s t agreement and was h i g h l y c o r r e l a t e d , a g a i n w i t h b e e r f i g u r e s b e i n g t h e l o w e s t c o r r e l a t i o n . E s s e n t i a l l y t h e outcome o f t h i s s t u d y i s t h a t s e l f - r e p o r t by members o f the g e n e r a l p o p u l a t i o n , w i t h the u s u a l component o f p r o b l e m d r i n k e r s , a r e found t o be h i g h l y r e l a t e d a c r o s s d i f f e r - ent methods o f measurement and d i f f e r e n t t ime p e r i o d s . Watson e t a l . (1984) have contended t h a t s e l f - r e p o r t s o f d r i n k i n g by a l c o h o l i c s a r e u n r e l i a b l e . T h e i r s t u d y i n v o l v e d f o l l o w - u p o f 100 t r e a t e d d i a g n o s e d a l c o h o l i c s and found the r e p o r t s o f e x - p a t i e n t s and c o l l a t e r a l s t o be s i g n i f i c a n t l y and p o s i t i v e l y r e l a t e d . I t was a l s o found t h a t e x - c l i e n t s t e n d e d t o r e p o r t s i g n i f i c a n t l y lower amounts t h a n c o l l a t e r a l s on s i x o f t e n t i m e p e r i o d s , w i t h no s i g n i f i c a n t d i f f e r e n c e on t h e r e m a i n i n g f o u r o f t e n , and f u r t h e r t h a t a t endency 215 e x i s t e d t o r e p o r t h i g h e r than c o l l a t e r a l s f o r the lower g e n e r a l consumpt ion range , and lower t h a n c o l l a t e r a l s f o r t h e h i g h e r g e n e r a l consumption r a n g e . The r e s u l t s were i n t e r p r e t e d as i n d i c a t i n g t h a t a l c o h o l i c s m i n i m i z e and t h a t t h o s e w i t h the most s e v e r e problems m i n i m i z e t h e most . The judgements o f c o l l a t e r a l s , whose o n l y r e q u i r e m e n t was t h a t they were " . . . l i k e l y t o know h i s whereabouts and c o n d i t i o n . . . " (p.344) on t e n d i f f e r e n t o c c a s i o n s o v e r e i g h t e e n months, were a p p a r e n t l y a c c e p t - ed as v a l i d and f u l l y a c c u r a t e w i t h o u t r e g a r d t o p o s s i b l e b i a s , i n t e r f e r e n c e o f a f f e c t toward t h e s u b j e c t , a low o r s p o r a d i c degree o f c o n t a c t , o r the p o s s i b l e d i f f e r e n c e i n the l o c a t i o n o f t h e d r i n k i n g and t h e l o c a t i o n o f the c o l l a t e r a l . The c o l l a t e r a l may be a s i g n i f i c a n t o t h e r w i t h s t r o n g f e e l i n g s about the c l i e n t ' s d r i n k i n g , o r more d i s t a n t and u n i n v o l v e d w i t h t h e c l i e n t , t h a t i s , p o s s i b l y i n a c c u r a t e by b e i n g too c l o s e , o r p o s s i b l y i n a c c u r a t e by b e i n g too f a r away. The c e n t r a l r e s u l t o f p o s i t i v e and s i g n i f i c a n t c o r r e l a - t i o n o f e x - c l i e n t and c o l l a t e r a l r e p o r t was l a r g e l y i g n o r e d . 216 M a i s t o e t a l . (1985) responded c r i t i c a l l y t o t h e Watson s t u d y , c i t i n g an inadequate and s e l e c t i v e l i t e r a t u r e rev iew t o s u p p o r t t h e i r h y p o t h e s i s , a v o i d - ance o f major c o n t r a d i c t o r y s t u d i e s , and m i s i n t e r p r e t a - t i o n o f n o n - s u p p o r t i v e d a t a such t h a t i t appeared s u p p o r t i v e o f t h e i r c o n t e n t i o n s . They a l s o c r i t i c i z e t h e r e s e a r c h d e s i g n and l a c k o f s p e c i f i c i t y o f a number o f f a c t o r s . P r i m a r i l y , however, M a i s t o and O ' F a r r e l l (1985) propose t h a t Watson e t a l . a r e imbedded i n a p e r c e p t u a l model which contends as a p r i m a r y a s s u m p t i o n t h a t p e r s o n w i t h problems r e l a t e d t o a l c o h o l consump- t i o n w i l l m i n i m i z e and deny as a n e c e s s a r y a s p e c t o f t h e d i s e a s e o f a l c o h o l i s m . Watson (1985) c i t e s f o r example , .the c u r r e n t l a y t h e o r y o f a l c o h o l i s m i n r e g a r d t o t h e " . . . d u b i o u s r e p u t a t i o n o f a l c o h o l i c s f o r c a n d i d - n e s s . . . " ( p . 3 4 4 ) . Beyond these c r i t i c i s m M a i s t o e t a l . f u r t h e r s u p p o r t s e l f - r e p o r t s as " . . . t h e most s e n s i t i v e and a c c u r a t e d a t a p o s s i b l e about d r i n k i n g and r e l a t e d b e h a v i o r s . . . " (p.450) and as a good g e n e r a l r e s e a r c h t o o l i n the a r e a o f d r i n k i n g problem i n t e r v e n t i o n s and s t r o n g l y suggest t h a t one r e s e a r c h s tudy s h o u l d no t endanger t h i s u s e f u l t o o l . 217 In a response t o M a i s t o and O ' F a r r e l l , Watson (1985) p o i n t s out t h a t the c u r v i l i n e a r i t y h y p o t h e s i s ( t h a t more s e v e r e u n d e r - r e p o r t i n g o c c u r s as t h e s e v e r i - t y o f the prob lem i s g r e a t e r ) i n one s tudy c i t e d was based on c l i e n t u n d e r - r e p o r t i n g d r i n k i n g d a y s , o v e r - r e - p o r t i n g l i m i t e d d r i n k i n g d a y s , and t h a t agreement on a b s t i n e n t days was g e n e r a l l y found . A g a i n he presumes t h a t c o l l a t e r a l r e p o r t s a r e the a c c u r a t e benchmark, and form the b a s e l i n e o f c o n t r a s t f o r c l i e n t r e p o r t s . I n a d d i t i o n t h i s i s not a c o n t r a s t o f l i n e a r i t y - c u r v i l i n - e a r i t y u s i n g r a t i o l e v e l numbers a p p r o p r i a t e t o such an a s s e r t i o n , but i s i n s t e a d based on t h r e e l o o s e l y o r d i n a l s t a t e s . I t i s a l s o t r u e t h a t the o n l y one o f t h e s e t h r e e open t o easy awareness by b o t h p a r t i e s i s n o n - d r i n k i n g o r a b s t i n e n c e , a c c u r a c y o f t h e o t h e r s can o n l y be e s t a b l i s h e d by c o u n t i n g o r by b r e a t h a l y z e r . Watson (1985) a v o i d e d q u a n t i t a t i v e da ta on consumpt ion i n h i s s t u d y i n o r d e r t o addres s the o v e r a l l m a l a d j u s t - ment o f the a l c o h o l i c as w e l l as t o a v o i d i n t e r f e r e n c e by un ique t o l e r a n c e l e v e l d i f f e r e n c e s . T h i s i s a weak de fense i n t h a t he c o u l d e a s i l y have c o l l e c t e d q u a n t i - t a t i v e and s u b j e c t i v e adjustment da ta and the 218 q u a n t i f i e d d a t a would have been an e x t r e m e l y u s e f u l o b j e c t i v e c r i t e r i o n o f h i s major v a r i a b l e s o f a d j u s t - ment. Heather e t a l . (1986) c r i t i c i z e Watson ' s r e s u l t s i n s o f a r as t h e y reduce the v a l i d i t y o f s e l f - r e p o r t as a r e s e a r c h t o o l , n o t i n g t h a t t h e r e i s no r e a s o n i n t h e r e s e a r c h t o s u s p e c t t h a t a moderate t endency t o u n d e r - r e p o r t consumpt ion w i l l be s y s t e m a t i c a l l y d i f f e r e n t a c r o s s t r e a t m e n t c o n d i t i o n s . P o l i c h ' s (1982) s t u d y s u p p o r t s t h i s p o i n t as w e l l . I t seems c l e a r t h a t t h e c o n t r o v e r s y o v e r t h e v a l i d i t y <of s e l f - r e p o r t o r i g i n a t e d i n , and i s m a i n - t a i n e d by r e f e r e n c e t o the t r a d i t i o n a l b e l i e f s o f t h e d i s e a s e mode l , p a r t i c u l a r l y w i t h r e f e r e n c e t o t h e c o n c e p t s o f " d e n i a l " and "hidden" o r "concea l ed" d r i n k i n g . I t a l s o appears c l e a r t h a t t h i s b e l i e f i s r e l a t i v e l y impermeable t o c o n t r a d i c t o r y e v i d e n c e , as n o t e d by Cook (1985) and Midanek (1982) . However, and t h i r d l y , i t appears from t h e r e p o r t s r e v i e w e d above t h a t s e l f - r e p o r t s by a l c o h o l i c s , by p r o b l e m d r i n k e r s , and by the g e n e r a l p o p u l a t i o n a r e c l o s e l y r e l a t e d t o 219 t r u e consumpt ion and would not be e x p e c t e d t o d i f f e r s y s t e m a t i c a l l y between d i f f e r e n t t r e a t m e n t c o n d i t i o n s . Thus as a r e s e a r c h t o o l , s e l f - r e p o r t s may g e n e r a l l y be a c c e p t e d as v a l i d f o r group c o n t r a s t p u r p o s e s , and may be p r e f e r r e d s i n c e , i n a d d i t i o n t o b e i n g v a l i d , s e l f - r e p o r t s a r e measures o f the t a r g e t b e h a v i o r , t h e c l i e n t has the b e s t a c c e s s t o the r e q u i r e d d a t a base ( i . e . h i s own d r i n k i n g b e h a v i o r ) , a c c u r a t e m o n i t o r i n g may be e a s i l y t a u g h t , t h e method i s i n e x p e n s i v e and r e l a t i v e l y easy t o c a r r y o u t , and s i n c e the d a t a y i e l d e d i s a t a r a t i o l e v e l and can be m a n i p u l a t e d by any o f a v a r i e t y o f s t a t i s t i c a l p r o c e d u r e s . 220 APPENDIX E C l i e n t Self-Monitorina Card Date Time Type of Drink Amount S i t u a t i o n 221 APPENDIX F The M i c h i g a n A l c o h o l i s m S c r e e n i n g T e s t (MAST) S e l z e r , 1980 M A S T ( S e l z e r S c a l e ) 1980 YES NO 0. Do y o u e n j o y a d r i n k now and then? 1. Do y o u f e e l y o u a r e a normal d r i n k e r ? (by n o r m a l we mean y o u d r i n k l e s s t h a n o r as much as most o t h e r p e o p l e . ) 2 . Have y o u ever awakened the morning a f t e r some d r i n k i n g t h e n i g h t b e f o r e and found t h a t y o u c o u l d n o t remember a p a r t o f t h e e v e n i n g ? 3 . Does y o u r w i f e , h u s b a n d , a p a r e n t , o r o t h e r n e a r r e l a t i v e e v e r worry o r c o m p l a i n about y o u r d r i n k i n g ? 4. Can y o u s t o p d r i n k i n g w i t h o u t a s t r u g g l e a f t e r one o r two d r i n k s ? 5 . Do y o u e v e r f e e l g u i l t y about y o u r d r i n k i n g ? 6. Do f r i e n d s and r e l a t i v e s t h i n k you a r e a normal d r i n k e r ? 7 . A r e y o u a b l e t o s t o p d r i n k i n g when y o u want to? 8. Have y o u e v e r a t t e n d e d a meet ing o f A l c o h o l i c s Anonymous (AA)? 9 . Have y o u g o t t e n i n t o p h y s i c a l f i g h t s when d r i n k i n g ? 1 0 . Has y o u r d r i n k i n g e v e r c r e a t e d prob lems between you and y o u r w i f e , husband, a p a r e n t , o r o t h e r n e a r r e l a t i v e ? 1 1 . Has y o u r w i f e , h u s b a n d , (or o t h e r f a m i l y members) e v e r gone t o anyone f o r h e l p about y o u r d r i n k i n g ? 12 . Have y o u e v e r l o s t f r i e n d s because o f y o u r d r i n k i n g ? 13 . Have y o u e v e r g o t t e n i n t o t r o u b l e a t work o r s c h o o l b e c a u s e o f d r i n k i n g ? 222 YES 14. Have you e v e r l o s t a j o b because o f d r i n k i n g ? 15. Have you e v e r n e g l e c t e d y o u r o b l i g a t i o n s , y o u r f a m i l y o r your work f o r 2 o r more days i n a row because y o u were d r i n k i n g ? 16. Do you d r i n k b e f o r e noon f a i r l y o f t e n ? 17. Have you e v e r been t o l d you have l i v e r t r o u b l e ? C i r r h o s i s ? 18. A f t e r heavy d r i n k i n g have you e v e r h a d d e l i r i u m tremens? ( D . T . ' s ) or 6evere s h a k i n g o r h e a r d v o i c e s o r seen t h i n g t h a t r e a l l y w e r e n ' t t h e r e ? 19. Have y o u e v e r gone t o anyone f o r h e l p about y o u r d r i n k i n g ? 20. Have you e v e r been i n a h o s p i t a l because o f y o u r d r i n k i n g ? 21. Have you e v e r been a p a t i e n t i n a p s y c h i a t r i c h o s p i t a l o r on a p s y c h i a t r i c ward o f a g e n e r a l h o s p i t a l where d r i n k i n g was p a r t o f the prob lem t h a t r e s u l t e d i n h o s p i t a l i z a t i o n ? 2 3 . Have you e v e r been a r r e s t e d f o r d r u n k d r i v i n g , d r i v i n g w h i l e i n t o x i c a t e d , o r d r i v i n g under the i n f l u e n c e o f a l c o h o l i c beverage? I f Y e s , how many t i m e s ? 24 . Have you e v e r been a r r e s t e d o r t a k e n i n t o c u s t o d y , even f o r a few h o u r s , because o f o t h e r drunk b e h a v i o r ? I f Y e s , how many t i m e s ? * 5 p o i n t s f o r d e l i r i u m tremens * * 2 p o i n t s f o r e a c h a r r e s t 223 APPENDIX G The L i f e S a t i s f a c t i o n Q u e s t i o n n a i r e S K I L L S , Vancouver H e a l t h Department 1980 L I F E SATISFACTION D a t e s : C L I E N T NO. S e s s i o n 1 P o s t Time 1 Time 2 1 Y e a r T o what e x t e n t do you f e e l s a t i s f i e d w i t h t h e f o l l o w i n g a r e a s o f y o u r l i f e ? P l e a s e t i c k the a p p r o p r i a t e r e s p o n s e . 1. I n t i m a t e R e l a t i o n s h i p s P l e a s e Comment 1 1 1 1 1 n o t a t a l l m i n i m a l l y somewhat m o s t l y c o m p l e t e l y 2 . J o b o r C a r e e r 1 1 1 1 1 n o t a t a l l m i n i m a l l y somewhat m o s t l y c o m p l e t e l y 3 . A b i l i t y t o Cope w i t h S t r e s s o r A n x i e t y 1 1 1 1 1 n o t a t a l l m i n i m a l l y somewhat m o s t l y c o m p l e t e l y 4 . A b i l i t y t o Cope w i t h D e p r e s s i o n 1 1 1 1 __1 n o t a t a l l m i n i m a l l y somewhat m o s t l y c o m p l e t e l y 5 . S o c i a l R e l a t i o n s h i p s o r S u p p o r t 1 1 1 1 1 n o t a t a l l m i n i m a l l y somewhat m o s t l y c o m p l e t e l y 6. S e l f - E s t e e m ( F e e l i n g Good A b o u t S e l f ) 1 1 1 1 1 n o t a t a l l m i n i m a l l y somewhat m o s t l y c o m p l e t e l y 224 7. A b i l i t y to Express Anger Please Comment 1 1 1 1 1 not at a l l minimally somewhat mostly completely 8. A b i l i t y to Express Feelings I 1 I 1 1 not at a l l minimally somewhat mostly completely Have any major l i f e events occurred that may be affect ing the manner in which you responded to the above statements? Yes No If yes, specify: 225 APPENDIX H The Profile of Mood States (POMS) McNair, D., Lorr, M., Droppleman, L. copyright 1981 Educational and Industrial Testing Service San Diego California, 92107 226 APPENDIX 1 S o c i a l Adjus tment S c a l e - S e l f R e p o r t (SAS-SR) Weissman M . 1974 Myrna M. Weissman, P h . D . Y a l e U n i v e r s i t y S c h o o l o f M e d i c i n e Department o f P s y c h i a t r y D e p r e s s i o n R e s e a r c h U n i t 904 Howard A v e n u e , S u i t e 2A New Haven , C o n n e c t i c u t , 06519 O c t o b e r , 1978 INFORMATION ON THE SOCIAL ADJUSTMENT SCALE - S E L F REPORT (SAS-SR) Deve lopment The SAS-SR d e r i v e s from t h e S o c i a l A d j u s t m e n t I n t e r v i e w . The d e t a i l s o f t h e deve lopment o f t h e S o c i a l A d j u s t m e n t S c a l e ( I n t e r v i e w ) can be found i n The D e p r e s s e d Woman; A S t u d y o f S o c i a l R e l a t i o n s h i p s , by M . M . Weissman, P h . D . , and Eugene S . P a y k e l , M . D . , U n i v e r s i t y o f C h i c a g o P r e s s , C h i c a g o , 1974. The d e t a i l s o f the deve lopment o f t h e SAS-SR and i t s r e l a t i o n t o t h e i n t e r v i e w v e r s i o n , i t s r e l i a b i l i t y and v a l i d i t y c a n be found i n a p a p e r by M . M . Weissman and S a l l y e B o t h w e l l , "Assessment o f S o c i a l A d j u s t m e n t by P a t i e n t S e l f - R e p o r t , " A r c h i v e s o f G e n e r a l P s y c h i a t r y 33: 1111-1115 (September) 1976. Norms i n d i f f e r e n t p s y c h i a t r i c p o p u l a t i o n s and i n a community sample c a n be f o u n d i n : M . M . Weissman, B . A . P r u s o f f , W.D. Thompson, P . S . H a r d i n g , and J . K . M y e r s . " S o c i a l A d j u s t m e n t by S e l f R e p o r t i n a Community Sample nd i n P s y c h i a t r i c O u t p a t i e n t s , " J o u r n a l o f Nervous and M e n t a l D i s e a s e 166, 5, 317- 326, 1978. A d m i n i s t r a t i o n The SAS-SR i s a p a p e r and p e n c i l t e s t c o m p l e t e d by t h e s u b j e c t . I t can a l s o be c o m p l e t e d by a r e l a t i v e o r s i g n i f i c a n t o t h e r a b o u t t h e s u b j e c t . A r e s e a r c h a s s i s t a n t s h o u l d be a v a i l a b l e t o i n i t i a l l y i n s t r u c t t h e s u b j e c t about t h e f o r m a t , answer q u e s t i o n s , and t o c h e c k f o r c o m p l e t i o n . 227 Scoring There are two scoring systems: 1) an overall adjustment score which is a B U B of a l l items divided by the number of items actually scored; 2) a role area mean score which is a sum of the items in a role area divided by the sum of the items actually scored in that area. The role areas are as follows: ROLE AREA ITEM NUMBER Work Outside Home Work at Home Work as a Student Social and Leisure Extended Family Marital Parental Family Unit Economic 1 7 13 19 30 38 47 51 54 6 12 18 29 37 46 50 53 T2B Study Patient Number Patient Initials 21 SAS Sr-Patient P.l of 6 Depression Research Unit 1 2 3 4 5 6 7 Date Rater's Initials: Computer Date (3-13) SOCIAL ADJUSTMENT SELF REPORT QUESTIONNAIRE We are interested in finding out how you have been doing in the last two weeks. We would like you to answer some questions about your work, spare time and your family l i f e . There are no right or wrong answers to these questions. Check the answers that best describes how you have been in the last two weeks. WORK OUTSIDE THE HOME Please check the situation that best describes you. I am 1 a worker for pay 4 retired (14) 2 a housewife 5 unemployed 3 a student Do you usually work for pay more than 15 hours per week? 1 YES 2 NO (15) Did you wdrk any hours for pay in the last two weeks? 1 YES 2 NO (16) Check the answer that best describes how you have been in the last two weeks. 1. How many days did you miss from work in the last two weeks? 1 No days missed. 2 One day. 3 I missed about half the time. 4 Missed more than half the time but did make at least one day. 5 I did not work any days. 6 On vacation a l l of the last two weeks. If you have not worked any days in the last two weeks, go on to Question 7. 2. Have you been able to do your work in the last 2 weeks? 1 I did my work very well. (18) 2 I did my work well but had some minor problems. 2-2-9 3 I needed h e l p w i t h work and d i d n o t do w e l l about h a l f t h e t i n e . 4 I d i d my work p o o r l y most o f the t i m e . 5 I d i d my work p o o r l y a l l t h e t i m e . 3 . Have you been ashamed o f how you do your work i n t h e l a s t 2 weeks? 1 I n e v e r f e l t ashamed. (19) 2 Once o r t w i c e I f e l t a l i t t l e ashamed. 3 About h a l f the t ime I f e l t ashamed. 4 I f e l t ashamed most o f t h e t i m e . 5 I f e l t ashamed a l l the t i m e . 4. Have y o u had any arguments w i t h p e o p l e a t work i n t h e l a s t 2 weeks? 1 I had no arguments and g o t a l o n g v e r y w e l l . (20) 2 I u s u a l l y go t a l o n g w e l l b u t had m i n o r a r g u m e n t s . 3 I had more than one argument . 4 I had many arguments . 5 I was c o n s t a n t l y i n arguments . 5. Have y o u f e l t u p s e t , w o r r i e d , o r u n c o m f o r t a b l e w h i l e d o i n g y o u r work d u r i n g the l a s t 2 weeks? 1 I n e v e r f e l t u p s e t . (21) 2 Once o r t w i c e I f e l t u p s e t . 3 h a l f t h e t ime I f e l t u p s e t . 4 I f e l t u p s e t most o f t h e t i m e . 5 I f e l t u p s e t a l l o f the t i m e . 5. Have you found y o u r work i n t e r e s t i n g t h e s e l a s t two weeks? 1 My work was a lmost a lways i n t e r e s t i n g . (22) 2 Once o r t w i c e my work was not i n t e r e s t i n g . 3 H a l f t h e t ime my work was u n i n t e r e s t i n g . 4 Most o f the t ime my work was u n i n t e r e s t i n g . 5 My work was always u n i n t e r e s t i n g . WORK AT HOME - HOUSEWIVES ANSWER QUESTIONS 7 -12 . OTHERWISE, GO ON TO QUESTION 13. 2-30 How many days did you do some housework during the last 2 weeks? 1 Every day. (23) 2 I did the housework almost every day. 3 I did the housework about half the time. 4 I usually did not do the housework. 5 I was completely unable to do housework. 8 I was away from home a l l of the last two weeks. During the last two weeks, have you kept up with your housework? This includes cooking, cleaning, laundry, grocery shopping, and errands. 1 I did my work very well. (24) 2 I did my work well but had some minor problems. 3 I needed help with my work and did not do i t well about half the time. 4 I did my work poorly most of the time. 5 I did my work poorly a l l of the time. Have you been ashamed of how you did your housework during the last 2 weeks? 1 '_ I never felt ashamed. (25) 2 Once or twice I felt a l i t t l e ashamed. 3 About half the time I felt ashamed. 4 I felt ashamed most of the time. 5 I felt ashamed a l l the time. Have you had any arguments with salespeople, tradesmen or neighbors in the last 2 weeks? 1 I had no argument and got along very well. (26) 2 I usually got along well, but had minor arguments. 3 I had more than one argument. 4 I had many arguments. 5 I was constantly in arguments. Have you felt upset while doing your housework during the last 2 weeks? 1 I never felt upset. (27) 2 Once or twice I felt upset. 3 Half the time I felt upset. 2 3 T 4 I f e l t u p s e t most o f t h e t i m e . 5 I f e l t u p s e t a l l o f t h e t i m e . 12 . Have y o u found y o u r housework i n t e r e s t i n g t h e s e l a s t 2 weeks? 1 My work was a lmost a l w a y s i n t e r e s t i n g . (28) 2 Once o r t w i c e ay work was not i n t e r e s t i n g . 3 H a l f t h e t ime my work was u n i n t e r e s t i n g . 4 Most o f t h e t ime my work was u n i n t e r e s t i n g . 5 My work was a lways u n i n t e r e s t i n g . FOR STUDENTS Answer Q u e s t i o n s 13-18 i f you go t o s c h o o l h a l f t i m e o r more . O t h e r w i s e , go on t o Q u e s t i o n 19. What b e s t d e s c r i b e s y o u r s c h o o l program? (Choose one) 1 F u l l Time (29) 2 3/4 Time 3 H a l f Time C h e c k t h e answer t h a t b e s t d e s c r i b e s how you have been t h e l a s t 2 weeks . 13 . How many days o f c l a s s e s d i d y o u miss i n the l a s t 2 weeks? 1 No days m i s s e d . (30) 2 A few days m i s s e d . 3 I m i s s e d about h a l f t h e t i m e . 4 M i s s e d more t h a n h a l f t i m e but d i d make a t l e a s t one d a y . 5 I d i d n o t go t o c l a s s e s a t a l l . 8 I was on v a c a t i o n a l l o f the l a s t two weeks . 14. Have y o u been^able t o keep up w i t h y o u r c l a s s work i n t h e l a s t 2 weeks? 1 I d i d my work v e r y w e l l . (31) 2 I d i d my work w e l l b u t had minor p r o b l e m s . 3 I needed h e l p w i t h my work and d i d n o t do w e l l about h a l f the t i m e . 4 I d i d my work p o o r l y most o f the t i m e . 5 I d i d my work p o o r l y a l l t h e t i m e . 23-2 15. During the last 2 weeks, have you been ashamed of how you do your school work? 1 . I never felt ashamed. (32) 2 Once or twice I felt a l i t t l e ashamed. 3 About half the time I felt ashamed. 4 I felt ashamed most of the time. 5 I felt ashamed a l l the time. 16. Have you had any arguments with people at school in the last 2 weeks? 1 I had no argument and got along very well. (33) 2 I usually got along well, but had minor arguments. 3 I had more than one argument. 4 I had many arguments. 5 I was constantly in arguments. 8 Not applicable; I did not attend school. 17. Have you felt upset at school during the last 2 weeks? 1 I never felt upset. (347) 2 Once or twice I felt upset. 3 Half the time I felt upset. 4 '_ I felt upset most of the time. 5 I f e l t upset a l l of the time. 8 Not applicable; I did not attend school. 18. Have you found your school work interesting these last 2 weeks? 1 My work was almost always interesting. (35) 2 Once or twice my work was not interesting. 3 Half the time my work was uninteresting. 4 Most of the time my work was uninteresting. 5 My work was always uninteresting. SPARE TIME - EVERYONE ANSWER QUESTIONS 19-27. Check the answer that best describes how you have been in the last 2 weeks. 19. How many friends have you seen or spoken to on the telephone in the last 2 weeks? 1 Nine or more friends. (36) 033 2 F i v e t o e i g h t f r i e n d s . 3 Two t o f o u r f r i e n d s . 4 One f r i e n d . 5 No f r i e n d s . Have you been a b l e t o t a l k about y o u r f e e l i n g s and prob lems w i t h a t l e a s t one f r i e n d d u r i n g t h e l a s t 2 weeks? 1 I can a lways t a l k about my i n n e r m o s t f e e l i n g s . (37) 2 I u s u a l l y can t a l k about my f e e l i n g s . 3 About h a l f the t ime I f e l t a b l e t o t a l k about my f e e l i n g s . 4 I u s u a l l y was not a b l e t o t a l k a b o u t my f e e l i n g s . 5 I was n e v e r a b l e t o t a l k about my f e e l i n g s . 8 Not a p p l i c a b l e ; I have no f r i e n d s . How many t i m e s i n the l a s t two weeks have you gone o u t s o c i a l l y w i t h o t h e r peop le? F o r example , v i s i t e d f r i e n d s , gone t o m o v i e s , b o w l i n g , c h u r c h , r e s t a u r a n t s , i n v i t e d f r i e n d s t o y o u r home? 1 More t h a n 3 t i m e s . (38) 2 T h r e e t i m e s . 3 T w i c e . 4 Once . 5 None. How much t i m e have you spent on h o b b i e s o r s p a r e t i m e i n t e r e s t d u r i n g the l a t s two weeks? F o r example , b o w l i n g , s e w i n g , g a r d e n i n g , s p o r t s , r e a d i n g ? 1 I s p e n t most o f my s p a r e t i m e on h o b b i e s (39) a l m o s t e v e r y d a y . 2 I spent some s p a r e t i m e on h o b b i e s some o f t h e d a y s . 3 I s p e n t a l i t t l e s p a r e t ime on h o b b i e s . 4 I u s u a l l y d i d not spend any t i m e on h o b b i e s b u t d i d watch T V . 5 I d i d no t spend any s p a r e t i m e on h o b b i e s o r w a t c h i n g T V . 2-3-4 23. Have you had open arguments with your friends in the last 2 weeks? 1 I had no arguments and got along very well. (40) 2 I usually got along well but had minor arguments. 3 I had more than one argument. 4 I had many arguments. 5 I was constantly in arguments. 8 No applicable; I have no friends. 24. If your feelings wee hurt or offended by a friend during the last two weeks, how badly did you take it? 1 It did not affect me or i t did not happen. (41) 2 I got over i t in a few hours. 3 I got over i t in a week. 5 It will take me months to recover. 8 Not applicable; I have no friends. 25. Have you felt shy or uncomfortable with people in the last 2 weeks? 1 I always felt comfortable. (42) 2 Sometimes I felt uncomfortable but could relax after a while. 3 About half the time I felt uncomfortable. 4 I usually felt uncomfortable. 5 I always felt uncomfortable. 8 Not applicable; I was never with people. 26. Have you felt lonely and wished for more friends during the last 2 weeks? 1 I have not felt lonely. (43) 2 I have felt lonely a few times. 3 About half the time I felt lonely. 4 I usually felt lonely. 5 I always felt lonely and wished for more friends. 27. Have you felt bored in your spare time during the last 2 weeks? 1 I never felt bored. (44) 2 I usually did not feel bored. 3 About half the time I felt bored. 255 r 4 I usually felt bored. 5 I was constantly bored. Are you a Single, Separated, or Divorced Person not living with a person o f opposite sex; please answer below: 1 YES, Answer questions 28 & 29. (45) 2 NO, go to question 30. 28. How many t i m e s have you been w i t h a d a t e t h e s e l a s t 2 weeks? 1 More t h a n 3 t i m e s . (46) 2 T h r e e t i m e s . 3 T w i c e . 4 Once . 5 N e v e r . 29. Have you been i n t e r e s t e d i n d a t i n g d u r i n g t h e l a s t 2 w e e k s . I f you have n o t d a t e d , would you have l i k e d t o ? 1 I was a lways i n t e r e s t e d i n d a t i n g . (47) 2 Most o f t h e t ime I was i n t e r e s t e d . 3 About h a l f o f t h e t ime I was i n t e r e s t e d . 4 Most o f t h e t ime I was n o t i n t e r e s t e d . 5 I was c o m p l e t e l y u n i n t e r e s t e d . FAMILY Answer Q u e s t i o n s 30-37 about y o u r p a r e n t s , b r o t h e r s , s i s t e r s , i n l a w s , and c h i l d r e n n o t l i v i n g a t home. Have y o u been i n c o n t a c t w i t h any o f them i n t h e l a s t two weeks? 1 YES, Answer q u e s t i o n s 30-37 . 2 NO, Go t o q u e s t i o n 36. 30 . Have you had open arguments w i t h your r e l a t i v e s i n t h e l a s t 2 weeks? 1 We a lways go t a l o n g v e r y w e l l . (48) 2 We u s u a l l y got a l o n g v e r y w e l l b u t h a d some m i n o r a r g u m e n t s . 3 I had more t h a n one argument w i t h a t l e a s t one r e l a t i v e . ?36 4 I had many argument*. 5 I was constantly in arguments. Have you been able to ta lk about your feel ings and problems with at least one of your re lat ives in the l a s t 2 weeks? 1 I can always ta lk about my feelings with at least one relat ive . (49) 2 I usually can ta lk about my feel ings . 3 About half the time I f e l t able to ta lk about my feelings. 4 I usually was not able to talk about my feel ings. 5 I was never able to ta lk about my fee l ings . Have you avoided contacts with your re la t ives these last two weeks? 1 I have contacted re lat ives regularly . (50) 2 I have contacted a re lat ive at least once. 3 I have waited for my relat ives to contact me. 4 I avoided my re la t ives , but they contacted me. 5 I have no contacts with any re la t ive s . Did you depend on your re lat ives for help, advice, money or friendship during the last 2 weeks? 1 I never need to depend on them. (51) 2 I usually did not need to depend on them. 3 About half the time I needed to depend on them. 4 Most of the time I depend on them. 5 I depend completely on them. Have you wanted to do the opposite of what your re lat ives wanted in order to make them angry during the l a s t 2 weeks? 1 I never wanted to oppose them. (52) 2 Once or twice I wanted to oppose them. 3 About half the time I wanted to oppose them. 4 Most of the time I wanted to oppose them. 5 I always opposed them. 35. Have you been worried about things happening to your relatives without good reason i n the las t 2 weeks? 1 I have not worried without reason. (53) 2 Once or twice I worried. 3 About half the time I worried. 4 Most of the time I worried. 5 I have worried the entire time. 8 Not applicable; ay relatives are no longer living. EVERYONE answer Questions 36 and 37, even i f your relatives are not living. 36. During the last two weeks, have you been thinking that you have let any of your relatives down or have been unfair to them at any time? 1 I did not feel that I let them down at a l l . (54) 2 I usually did not feel that I let them down. 3 About half the time I felt that I let them down. 4 Most of the time I have felt that I let them down. 5 I always felt that I let them down. 3 7 . During the last two weeks, have you been thinking that any of your relatives have let you down or have been unfair to you at any time? 1 I did not feel that they let me down at a l l . (55) i f 2 I fel t that they usually did not let me down. 3 About half the time I felt they let me down. 4 I usually have felt that they let me down. 5 I am very bitter that they let me down. Are you living with your spouse or have been living with a person of the opposite 6 e x in a permanent relationship? 1 Y E S , Please answer questions 3 8 - 4 6 . (56) 2 NO, Go to question 47 . 3 8 . Have you had open arguments with your" partner in the last 2 weeks? 1 We had no arguments and we got along well. (57) 2 We usually got along well but had minor arguments. 3 We had more than one argument. 4 We had many arguments. 5 We were constantly in arguments. 238 Have you been able to talk about your feelings and problems with your partner during the last 2 weeks? 1 I could always ta lk freely about ay fee l ings . (58) 2 I usually could ta lk about my feel ings . 3 About hal f the time I fe l t able to t a l k about ay feelings. 4 I usually was not able to talk about ay feel ings . 5 I was never able to talk about ay fee l ings . Have you been demanding to have your own way at home during the last 2 weeks? 1 I have not insisted on always having ay own (59) way. 2 I usually have not insisted on having ay own way. 3 About hal f the time I insisted on having my own way. 4 I usually Insisted on having my own way. 5 I always insisted on having ay own way. Have you been bossed around by your partner these l a s t 2 weeks? 1 Almost never. (60) 2 Once in a while. 3 About ha l f the time. 4 Most of the time. 5 Always. How much have you fe l t dependent on your partner these last 2 weeks? 1 I was independent. (61) 2 I was usually independent. 3 I was somewhat dependent. 4 was usually dependent. 5 I depended on my partner for everything. How have you f e l t about your partner during the l a s t 2 weeks? 1 I always f e l t affect ion. (62) 2 I usually f e l t affect ion. 3 About half th« ti»e I f e l t d i s l i k e and h a l f the time aff e c t i o n . 4 I usually f e l t d i s l i k e . 5 I always f e l t d i s l i k e . CHILDREN Have you had unmarried children, stepchildren, or foster children living at home during the last two weeks? 1 YES, Answer questions 47-50. (66) 2 NO, Go to question 5 1 . 240 47. Have you been interested in what your children are doing - school, play or hobbies during the last 2 weeks? 1 I was always interested and actively involved. (67) 2 I usually was interested and involved. 3 About half the tine interested and half the t ine not interested. 4 I usually was disinterested. 5 I was always disinterested. 48. Have you been able to talk and l i s t e n to your chi ldren during the last 2 weeks? Include only children over the age of 2. 1 I always was able to communicate with them. (68) 2 I usually was able to communicate with them. 3 About half the time I could communicate. 4 I usually was not able to communicate. 5 I was completely unable to communicate. 8 Not applicable; no chi ldren over the age of 2. 49. How have you been getting along with the chi ldren during the la s t 2 weeks? 1 I had no arguments and got along very we l l . (69) 2 . I usually got along well but had minor arguments. 3 I had more than one argument. 4 I had many arguments. 5 I was constantly in arguments. 50. How have you fe l t toward your chi ldren these las t 2 weeks? 1 I always fe l t affect ion. (70) 2 I mostly f e l t affection. 3 About half the time I f e l t affection. 4 Most of the time I did not feel af fect ion. 5 I never f e l t affection toward them. FAMILY UNIT Have you ever been married, ever l ived with a person of the opposite sex or ever had children? Please check. 1 Y E S , Please answer questions 51-53. (71) 2 NO, Go to question 54. 241 51. Have you worried about your partner or any of your chi ldren without any reason during the last 2 weeks, even i f you are not l i v i n g together now? 1 I never worried. (53) 2 Once or twice I worried. 3 About half the time I worried. 4 Most of the time I worried. 5 I always worried. 8 Not applicable; partner and chi ldren not l i v i n g . 52. During the last 2 weeks have you been thinking that you have let down your partner or any of your children at any time? 1 I did not feel that I let them down at a l l . (73) 2 I usually did not feel that I l e t them down. 3 About half the time I f e l t that I l e t them down. 4 Most of the time I have f e l t that I l e t them down. 5 I le t them down completely. 53. During the last 2 weeks, have you been thinking that your partner or nay of your children have l e t you down at any time? 1 I never fe l t that they l e t me down. (74) 2 I f e l t they usually did not le t me down. 3 About half the time I f e l t they l e t me down. 4 I usually fe l t they let me down. 5 I feel b i t ter that they have l e t me down. FINANCIAL - EVERYONE PLEASE ANSWER QUESTION 54. 54 . Have you had enough money to take care of your own and your family's f inancial needs during the las t 2 weeks? 1 I had enough money for needs. (75) 2 I usually had enough money with minor problems. 3 About half the time I did not have enough money but did not have to borrow money. 4 I usually did not have enough money and had to borrow from others. 5 I had great f inancial d i f f i c u l t y . 2 1 1 (76-80) V I S I T FORM CARD 242

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